HomeMy WebLinkAbout600 LOCUST GROVE DR - SPECIAL INSPECTIONS - 5/9/2012Planning, Development & Transportation Services
„�� 9yr Community Development & Neighborhood services
Collins281 North College Avenue
F6Mt /'� P.O Box580
'� Fort Collins, CO 80522.0580
970.416.2740
970.224.6134- fax
fcgov. com D �
Combustion Safety Test Compliance Form 'l(UJu
Replacement of Natural Draft Appliances in Existing Houses MAY 14 2w D
f L
Address: �oC� LU-CC,s:� .s` "� Permit Number: 411 zU�-�oU
Approved Agency:
Technician Name (print): lc a_- Company 1 a �,_p,�
Technician Signature: Date Z
Appliance Tested:
Appliance Replace
Worst Case Conditions:
Spillage Duration (in seconds): Carbon Monoxide (parts per million):
Pass Fail Date Tested: !S 1 Z
(Failed test requires owner's signature acknowledging results.)
Natural Conditions:
Spillage Duration (in seconds): Carbon Monoxide (parts per million):
Pass �_ Fail Date Tested: S 'Z
(Failed test requires corrections until test passes under 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
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