HomeMy WebLinkAbout6020 HUNTINGTON HILLS DR - SPECIAL INSPECTIONS - 12/19/2012FROM :NCA
FAX NO. :9702299983 Jan. 26 2012 10:05AM P2/3
Planning, Development & Transportation Services
�+ community Development & N®Iphporhood 8ervlcea
city td 281 North College Avenue
P.C. Box 680
Fort othns Fort Colllne, 00 80522.0880
970,410.2740
970.224.e13a fax
hgov.com
Combustion Safety Test Compliance Form
Replacement of Natural Draft Appliances in Existing Houses
Address: I.Ao i Permit Number:
Approved Agcncy:
I hereby attest that I have been trained as an Approved Agency and have perfurmod the following
Comhustion Safety Test in accordance with Fort Collins Combustion Safety Test Guide
Version 5, February 2012.
Technician Name (print):... �,a....� Company /V�A_,
Technician Signature: Date
Appliance Tested: v/r7iG`2
Appliance Replaced- _ _&-, -4 ok 01 zt
Worst Case Conditions:
Spillage Duration (in seconds): ^ Carbon Monoxide (parts per million):
Pass -, 'I Fail
Natural Conditions:
Spillage Duration (in seconds):
Pass Fail
Date Tested: AV /� r 2-
Carbon Monoxide (parts per million):
Date Tasted:
(Failed test requires corrections until test passes under Natural Conditions.)
Technician's recommendations to correct tested appliance failure:
Failed Worst Case Conditions:
I certify that I am the legal owner of the above listed property and hereby acknowledge that my appliance
has failed a Combustion Safety Test under worst -case conditions. T acknowledge that I have received a
combustion appliance safety iufirrmation sheet.
Owner's Name (print)
Owner's Signature _
CST:replacemenVnatural•drafd4.25.12
Date