HomeMy WebLinkAbout423 BUCKEYE ST - SPECIAL INSPECTIONS - 3/26/2014FROM :NCA FAX NO. :9702299983 Apr. 18 2014 10:49AM P4/5
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Planning, Development & Transportation Services
city, Q Community DswetoproW & NWgt6ordood Services
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Cottins P.O. COCO.0580
870A16.2740
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Combustion Safety Test Compliance Form
Replacement of Natural Draft Appliances in Existing Houses
44 Address: 23 ..... Permit.Nttmher:v
Approved Agency:
1 hereby attest that I have been trained as an Appmvcd Agency and have performed the following
Combustion Safety Test in accordance with Fort Collins Combustion Safety Test Guido
Version 5, Februa'ry2012.
Technician Name (print): i � �a?s� �ompany-.....02/ea _
�'C , ! $�'"' c5 `•
Technician Signature: _� , _�-'" Dale
Appliance Tested: tz--Yc & `4
Appliance Replaced: /ZZ17401- �:-2_�,.. _...._. ...... '
Worst Case Conditions: 11
Spillage Duration (in second ): _.., !.Q Carbon Monoxide (parts per million):
Pass _ .._ Fail Date Tested: ,.
Natural Conditions:
Spillage Duration (in seconds):
Pass Fail
Carbon Monoxide (parts per million) -.-
Date Tested:
(Failed test requires corrections until tesi passes under Natural Conditions.)
'.technician's recommendations to correct tested appliance failure:
Failed Worst Case Conditions:
1
1 certify that I am the legal owner of the above listmi 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•drafl/4.25.12
Date