HomeMy WebLinkAbout6714 ROSE CREEK WAY - SPECIAL INSPECTIONS - 3/13/2014t of Community Development
Collins PO Bo5810F6Cirt
281 N. College Ave.
Fort Collins, CO 80522
970.416.2740
970.224.6134 (fax)
fcgov. com/development
Combustion Safety Test Compliance Form
Replacement of Natural Draft Appliances in Existing Houses
Address: C,'? 14 Rose CI-ecK W y Permit #: 61 4 j 3 b i
Approved Agency: T
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): �e5 �r � Company
Technician Signature: Date
Appliance Tested: IA4 +,Pr-N&Jf4�
Appliance Replaced:
Worst Case Conditions:
Spillage Duration (in seconds): _� Carbon Monoxide (parts per million):
Pass Fail Date Tested: 1 - / 3- / y
Natural Conditions:
Spillage Duration (in seconds)
Pass Fail
Carbon Monoxide (parts per million):
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-draft/4.25.12
Date