HomeMy WebLinkAbout425 BAYLOR ST - SPECIAL INSPECTIONS - 10/1/2013Oct 04 13 03:48p Rues, LLC 970-619-8074 p.2
11:37:0s am. 09-29-2012 111
'0-224-6134
of
F6rtollins
Community Development
281 N. CollegeAvm
PO Box Sao
Fort CollIns. CD 60522
970.416.2740
07o.224.6134 MA
kRzewdevelopment
Combustion Safety Test Compliance Form
Replacement of r4atural Draft Appliances in Existing Houses
Permit #: B I 1 0
i
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): arwl l l omPmy �� l
Technician Signa Date /G / I
Appliance Tested:
Appliance Replact
Toast Case Conditions: -
Spillage Duration (in seconds):
Pass Fail
Natural Con ' tons:
Spillap Dmaqn (in seconds):
Pass Fail
Carbon Monoxide (parts per million):
DateTested* G
Carbon Monoxide (parts per million):
Date Tested:
Gaited test requires corrections uan'l test passes ander Natural Cnrpd Ons)
Technician's recommendations to cornet tested appliance failure:
Railed Worst Case Conditions:
I certify that I am the legal owner of the above listed property and hereby admowledge that my appliance
has failed a Combustion Safety Test under worst -case conditions. I admowledge that I have received a
combustion appliance safety information sheet.
Owner's Name (pint)
Owner's Signature
CSTleplacementjfMMtal draftf4.25.12
Date