HomeMy WebLinkAbout4900 SAWHILL DR - SPECIAL INSPECTIONS - 12/19/2013etanning, uevetopment & t ransportation Services
Community Development & Neighborhood Sen•tces
City of 281 North College Avenue
F6rf Collins P.0.Box 5£0
! Fort Collins, CO £0522.05£0
970.416.2740
970.224.6134- tax @�
fcoov.con i
APR 1 1 204
Combustion Safety Test Compliance Form BY:
Replacement of Natural Draft Appliances in Existing Houses
Address: gGf%i PeimitNuniber:
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
Technician Naive
Technician Signature:
Appliance Tested: —
Appliance Replaced:
Worst Case Conditions:
Version 5, February 2012.
Company AY. 4-1'd �4u t �
Date Q,- ift-- 1-1
Spillage Duration (in seconds): ?/ Carbon Monoxide (parts per million): �
Pass Fail Date Tested:
Natural Conditions:
Spillage Duration (in seconds): Carbon Monoxide (parts per million):
Pass -e" Fail Date Tested: 11 - "30' J�
(Failed test requires corrections until testpasses uuderNatural 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 sae information s1h c--
t
Owner's Name
Owner's Signature
CST:replacement/natural-draftl4 25.12
077