HomeMy WebLinkAbout4342 SHADOWBROOKE CT - SPECIAL INSPECTIONS - 5/3/2013Planning, Development & Transportation Services
City �( Community Development & Neighborhood Services
ort (Collins P.O.281 BoNorth College Avenue
x 580
F P.O. Bo
Fort Collins, CO 80522.0580
970.416.2740
970.224.6134- fax
fcgov.com
Combustion Safety Test Compliance Form
Replacement of Natural Draft Appliances in Existing Houses
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Address: r"' JhJ r� t7�� Permit Number:
Approved Agency:
I 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. , , 1V
Technician Name
Technician Signat
Appliance Tested:
Appliance Replaced: F L)rna lei
Worst Case Conditions:
Spillage Duration (Xseecods): Carbon Monoxide (parts.per million):
Pass Fail Date Tested:Natural Condit
Spillage Duration (in seconds): Carbon Monoxide (parts per million):
Pass Fail Date Tested:
(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. I acknowledge that I have received a
combustion appliance safety information sheet.
Owner's Name (print)
Owner's Signature
CST:replacement/natural-dra8/4.25.12
Date