HomeMy WebLinkAbout624 SMITH ST - SPECIAL INSPECTIONS - 2/2/2015City ®f Community Development
Collins 281 N. College Ave.
PO Box 580
F6rt
Fort Collins, CO 80522
970.416.2740
970.224.6134 (fax)
fcgov. com/development
Combustion Safety Test Compliance Form
Replacement of Natural Draft Appliances in Existing Houses
Address: y :2'�' _57-� Permit #: / 5'"nwoo
Approved Agency:
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):— U / C �%� lT .f. Company
Technician Signature: f i , s�r�� Date r-7- /2/I T
Appliance Tested: („ )oti 1 P. r Ne-r,,- " P r,—
Appliance Replaced: t,.,. ' -e r
Worst Case Conditions:
Spillage Duration (in seconds): Carbon Monoxide (parts per million): j I0; fiI _
v
Pass X Fail Date Tested: ? / Z 11 <'
Natural Conditions:
Spillage Duration (in seconds):
Pass Fail
Carbon Monoxide (parts per million):
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
CST: replacement/natural-draft/4.25.12
Date