HomeMy WebLinkAbout4130 SNOW RIDGE CT - SPECIAL INSPECTIONS - 6/7/2013City Of Community Development
Fort Collins PO College Ave.
PO Boo x 580
Fort Collins, CO 80522
970.416.2740
970.224.6134 (fax)
fcgov.com/deve/opment
Combustion Safety Test Compliance Form
Replacement of Natural Draft Appliances in Existing Houses
Address: Y13 o 5n0w J-re CA, Permit #: 5 13b c)3 a 6
Approved Agency:
I hereby attest that I have performed the following Combustion Safety Test in accordance with
Fort Collins Combustion Safety Test Guide Version 5, February 2012.
Technician Name (print): N1, &iArvu5co Company X-f- f rr-d, CA-3
Technician Signature. Date Z7111
Appliance Tested: Wad he,-k
Appliance Replaced: Waai�lkek
Worst Case Conditions:
Spillage Duration (in seconds): 5 Carbon Monoxide (parts per million): %
Pass Fail Date Tested: tp
Natural Conditions:
Spillage Duration (in seconds): 1 S� Carbon Monoxide (parts per million): 7
Pass Fail Date Tested: G /
(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-draft/4.25.12
Date