HomeMy WebLinkAbout1133 BENT TREE CT - SPECIAL INSPECTIONS - 7/29/2014FROM :NCR FAX NO. :9702299983 Sep. 30 2014 01:43PM P3/3
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��»» l Planning, Development & Transportation Services
City of Communtty Development & Nek0ftrhood Services
Fort Cottins °� s,COeo 2.o5ao
870.224.0194• tax
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Combustion Safety Test Compliance Form
Replacement of Natural Draft Appliances in Existing Houses
Address: Permit Number:L��
Approved Agency:
1 hereby attest that I have been trained as an Approved Agency and have performed the following
Combustion Surety Test in accordance with Fort Collins C'ombustio6 Safety Test Guide
Version 5, February 2012.
Technician Name (print):
{ �iJ !(dn Y) —_.Company _.A .rjL.
Technician Signature: Date_
Appliance Replaced: � _/.i, Y\OIC ALA _ ..... -
Appliance Tested:
Worst Case Conditions:
Spillage Duration (in sserconds): �. Carbon Monoxide (parts per milli n):
Pass 7'�T Fail Date Tested: '-r
Natural Conditions: Spillage Duration Duration (in seconds): _._ Carbon Monoxide (parts per million):
pass Fail 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
CS' I':replacemen t/natural-draft/4.25.12
Date