HomeMy WebLinkAbout4436 CRAIG DR - SPECIAL INSPECTIONS - 2/17/2015970-224-6134
11:37:05 a.m. 09-29-2012 ill
Community development
City, ®f _ 281 N. College Ave.
PO Box 580
Fort Collins, CO 80622
970.416.2740
970.224.6134 (fax)
fcgov com/development
Combustion Safety Test tCemmpftimee Form
Replacement off Naturral Draft Appliances iR Md9l inn Houses 3
Address: q`A b Permit* /91-5,0 //,7(D
Approved Ageneyo
I hereby attest that I have performed the following Combustion Safety Test in accordance with
Fort Collins Combustion Safety Test Guide Version 5. February 2012.
Technician Name (print): Mo-14 'mod$--k- Company &,-- FrS4,t Ic' i%fin
Technician Signature: —?�ri �-�- Date 2 - 0 -rU—
ApplianeeTested: I-njA%p� In�4r-
Appliance Replaced: k&46,-- tv-A4-e-�
Worst (Case 1Condiflo ms:
Spillage Duration (m seconds):
Pass Fail X
Carbon Monoxide (parts per million):
Date Ti ested:
Natural cCondifiens. �
Spillage Duration (in seconds): U Carbon Monoxide (parts per million):
Pass Fail Date Tested*
(Failed rest regceeres corPeeraons nizeef rest passes m2i&tr Raearad Comdidons)
Technician's recommendations to correct tested appliance failure:
Famed Worst Case tCandi9n®ns:
I certify that I am the legal owner of the above listed property and hereby aciutowledge that my appliance
has failed a Combustion Safety Test under worst -ease condIRions. I acltnowledge that I have received a
combustion appliance safety information sheet.
Owner's Name (print)
Owner's Signature
CST:repIacementtaatural-draN4.25.12
PiN P it-t-.K v "- vi r, uj t o
Date