HomeMy WebLinkAbout4640 VENTURI LN - SPECIAL INSPECTIONS - 6/13/2012Planning, Development & Transportation Services
City of
art Collins
Community development b NeIghbodwod Services
281 North College Avenue
P.O. Box 580
Fort Collins, CO 80522,0580
970.418.2740
970.224.8134-lax
tcgov.com
Combustion Safety Test Compliance Form
Replacement of Natural Draft Appliances in Existing Houses
Address: 4L04 & - r j L,,, a Permit Number: G— 01-00 1
Approved Agency:
Technician Name (Print): e i V Company . U fain s . V
Technician Signature: Date
Appliance Tested:
Appliance Replace
Worst Case Conditions:
Spillage Duration (in seconds): - - Carbon Monoxide (parts per million): t� rl e—
Pass '5.< Fail Date Tested: n
(.Failed test requires owner's signature acknowledging result;.)
Natural Conditions:
Spillage Duration (in seconds): 0 Carbon Monoxide (parts per mullion): C�
Pass % Fail Date l rested: Ir, ! I'll., a
(Failed test requires corrections until test passes tinder Natural Conditions.)
Technician's recommendations to correct tested appliance failure:
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 Date -.2d/ L.
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