HomeMy WebLinkAbout4702 DUSTY SAGE DR - SPECIAL INSPECTIONS - 4/10/2014Fort of
Replacement
Address: 1-/7 D 2- tl vS
Approved Agency:
Technician Name (print):
Technician Signature:
Appliance Tested:
Appliance Replaced:
Worst Case Conditions:
Spillage Duration (in seconds):
Pass jr R
(Failed test req
Natural Conditions:
Spillage Duration (in seconds):
Pass _,2C- F
(Failed test requires i
Technician's recommendations
ing, 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
Lion Safety Test Compliance Form
'Natural Draft Appliances in Existing Houses
\ SG�Qi Permit Number: v�
Company Allen SZi�i Ge
Date
3 Carbon Monoxide (parts per million):
Date Tested:
owner's signature acknowledging results.)
'Carbon Monoxide (parts per million): 7
DateTested:
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 appliance safety information sheet.
Owner's Name (print)
Owner's Signature
Date