HomeMy WebLinkAbout601 JUSTICE DR - SPECIAL INSPECTIONS - 8/21/2012Fort Collins
Planning,, Development & Transportation Zervices
Community Development& Neighborhood Services
281North College Avenue
P.O. Box 580
Fort Collins, CO 80522.0580
970.416.2740
9 i 0.224.6134= fax
fcgov.com
Combustion Safety Test Compliance Form
Replacement
-o-f-NatumlDraft Appliances in Existing Houses
Address: `� �� /' fr r.�r Permit Number:
Approved Agency:
1 hereby attest that I have been trained.as an Approved Agency and have performed the following
Combustion Safety Test in accordance: with Fort Collins Combustion; Safety Test Guide,
Version 5, February 2012. �y/�
Technician Name (print): ,� v ^ j ?�: /�` e2c1" ,Company l r' '/�2S
Technician.Signature: Date Y—I `jam
Appliance Tested: fe Ln-c-
Appliance Replaced:_ C✓w>_.L.
Worst Case Conditions: j.0
Spillage Duration (in seconds):/ Carbon Monoxide (parts per million): c`J
Pass. Fail.. - Date Tested:
Natural, Conditions:
Spillage Duration (in seconds): , U Carbon Monoxide (parts per million):
Pass��Fail Date Tested: 0—
(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. l acknowledge that I have received a
combustion appliance safety information sheet.,
Owner's Name.'(print)
'Owner's Signature Date
CST:replacement/natural-draft/4.25.12