HomeMy WebLinkAbout4702 DUSTY SAGE DR - SPECIAL INSPECTIONS - 4/10/2014 (2)annin9, Development & Transportation Services
City ®f
Fort Collins
Replacement
Address: t-( 7 0
Approved Agency:
Technician Name (print):
Technician Signature: )
Appliance Tested:
Appliance Replaced:
Worst Case Conditions:
Spillage Duration (in seconds):
Pass ;- F
(Failed test
Natural Conditions:
Spillage Duration (in seconds):
Pass 1
(Failed test requires
Technician's recommendations
Community Development d Neighborhood Services
281 North College Avenue
P.O. Box 580
Fort Collins. CO 80522.0580
970.416.2740
970.224.6134-lax
Icgov.com
-.ion Safety Test Compliance Form
Natural Draft Appliances in Existing Houses
v
1* G/
Permit Number: /
Company Allen Ser�j ce
Date Gf /V
111�4_?Ir
3 Carbon Monoxide (parts per million):
Date Tested: '7�/o''fy
owner'.v signature acknowledging results)
Carbon Monoxide (parts per million): 7
Date Tested:
until test passes under Natural Conditions.)
correct tested appliance failure:
I certify that I am the legal own r 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 ap liance safety information sheet.
Owner's Name (print)
Owner's Signature Date