HomeMy WebLinkAbout424 PINE ST - SPECIAL INSPECTIONS - 5/12/2014F
Clty of Community Development
7 1 281 N. College Ave.
6rt Collins PO Box 580
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: �s �` / /`,1� S i ci�r . Permit #: 1j 7 O 2 ,2-
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): r'UJ 5tl. Company )0 T ✓�%DY �'S ��� �� ^'� �--
Technician Signature: �" f . r�,� Date ='
Appliance Tested:
Appliance Replaced:
Worst Case Conditions:
Spillage Duration (in seconds)
Pass Fail
Natural Conditions:
Spillage Duration (in seconds): _
Pass Fail
Carbon Monoxide (parts per million):
Date Tested:
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