HomeMy WebLinkAbout4306 NEW BEDFORD DR - SPECIAL INSPECTIONS - 3/6/2014.!
Planning, Development & Transportation Services
Community Development & Neighborhood Services -
281 North College Avenue
P.O. Box 580
Fort Collins, CO 80522.058
970.416.2740 o` JP v/
970.224.6134-fax
fcgov.com '
Combustion Safety Test Compliance Form
Repla,,ceement of Natural Draft Appliances in Existing Houses
Address: � /ao & l t ,z , Permit Number: { {, zj (.
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):
Carbon Monoxide (parts
million): Z
Natural Conditions:
Spillage Duration (in seconds): Carbon Monoxide (parts per million):
Pass Fail Date Tested:
v
-(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, Date
CST:replacement/natural-draft/4.25.12
MEMO
Planning, Development & Transportation Services
Community Development & Neighborhood Services
281 North College Avenue
P.O. Box 580
Fort Collins, CO 80522.0580
970.416.2740
970.224.6134-fax,
fcgov.com
Combustion Safety Test Compliance Form
Replacceem/ent of Natural Draft Appliances in Existing Houses
Address: ��a ro e 1/7 j � L J Permit Number: 57
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. r
Technician Name (print): t J mpanA�Lg_,�� 06�?4,
Technician Sign a Date
Appliance Tes e.:
Appliance Replaced:
Worst Cgse Conditions:
Spillage, Duration .(in seconds): Carbon Monoxide (parts per million): J 7
Pass Fail Date Tested: 3Aiz1
Natural Conditions:
Spillage Duration (in seconds): Carbon Monoxide (parts per million):
Pass Fail Date Tested:
v
(Failed test requires, corrections until test passes under Natural Conditions.)
Technician'srecommendations 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, Date
CST:replacement/natural-draft/4.25.12