HomeMy WebLinkAbout600 REPUBLIC DR - SPECIAL INSPECTIONS - 8/7/2012City of
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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
Replacement of Natural Draft Appliances in Existing Houses
Address: 4 0 0 ,(gyp ��; �r Permit Number:
Approved Agency:
Technician Name (print): �.' Company,A
Technician Signature: fy-v Date
t; V
Appliance Tested: V/
Appliance Replaced:
Worst Case Conditions:
Spillage Duration (in seconds):
Pass
Carbon Monoxide (parts per million): S
Fail Date Tested:
(Failed test requires owner's signature acknowledging results:)
Natural Conditions:
Spillage Duration (in seconds): Carbon Monoxide (parts per million):
Pass Fail Date Tested:
(Failed test requires corrections unfit 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