HomeMy WebLinkAbout944 W MOUNTAIN AVE - SPECIAL INSPECTIONS - 3/9/2015MAR/31/2015/TUE 11:54 AM DELTA MECHANICAL -AZ FAX No.480-898-0005
P. 003
Planning, Development $ Transportation Services
city.
� �Community Devulopment & Neighborhood Services
�9 281 North College Avenue
P.O. Box 5BO
g F+ort9 Collins Fart Collins. CO 60522,0580
970.416.2740
N 970.224.6134-fax
fcgov.com
Combustion Safety 'Test Compliance Form
Replacement of Natural Draft Appliances in E:olstvng Houses
Address: clqqd a Permit Number. _ JB(6j b 1(o l S
Approved Agency:
I hereby attest that I have been trained as an ,Approved Agency and have performed the following
Combustion Safety Test in accordance with Fort Collins Combustion Safety Test Guide
Version 5, February 2012. Technician Name (prin Company_oblotj"o bt-I4o. f&e6aYlICa1
Technician Signature: bate 3 q I 15
Appliance Tested: ft
Appliance Replaced:
Worst Case Conditions:
Spillage Duration (in seconds): _
pass --V—/ Nail
Natural Conditions:
Carbon Monoxide (parts per million):
bate Tested: 3�9�15
Spillage Duration (in seconds): Carbon Monoxide (parts per million);
Pass bail Date Tested:
(Failed test requires corrections until testpasses 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 appliancc
has failed a Combustion Safety Vest under worst -case conditions. I acknowledge that I have received a
combustion appliance safety information sheet.
Owner's Name (print)
Owner's Signature_
CST:rcplacemen[/natural-draft/4.25.12
Date