HomeMy WebLinkAbout508 VILLANOVA CT - SPECIAL INSPECTIONS - 2/11/2014Planning, Development & Transportation Services
, community Develo � „ �r �� ity pmeM &Neighborhood Services
BMW W%S � � P.O.281 BOX 580 college Avenue
P.O. Sox 580
Fort Collins. CO 80522.0580
97DAIS2740
970.224.6134-fax
kpmaom
Combustion Safety Tat Compliance Form
Replaceneitit of Natural Draft Appliances in Existing Houses
Address: 56 ��i' /� ri a v I? �- Permit Number: A / y� �a _7
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.
Technician Name (print): 'e_ k LJ i Company .'vr
Technician Signature: a Date 2- //- zo / y J
Appliance Tested: W 0-4, r V i P e
Appliance Replaced: W edip hem e—
Worst Case Conditions: ``��
Spillage Duration (in seconds): l� Carbon Monoxide (parts per million):
Pass Fail Date Tested: Z - //' / `/
Natural Conditions:
Spillage Duration (in seconds): iS Carbon Monoxide (parts per million): I Z
Pass —X— Fail Date Tested:
(Failed feltrequirlens corrections unh7festpasm underNahnal Cont&o) S)
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) n O
Owner's Signature Date Z //- zo l 4f
CST=Tlacemant/naUMd-drafV4.25.12