HomeMy WebLinkAbout4112 WARBLER DR - SPECIAL INSPECTIONS - 9/29/2014FROM :NCR
FAX NO. :9702299983 Oct. 16 2014 03:27PM P3/4
Fowl Cooing
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Planning, Development & Transportation Services
ComMunity Development d Nelohhorhood Services
281 North Oopeye Avenue
P_O. BOX $so
Fort COMM, co 805U.0sso
970AIS2740
970.224.9134- fox
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Combustion Safety Test Compliance Form
Replacement of [Natural Draft Appliances in Existing Houses
Address: g (I Z _ r �� 12i, Permit Number:
Approved Agency:
I hereby attest that I have been trained as an Approved Agency and have performed the following
Combustion Safety'i'est in accordance with Fort Collins Combustion Safety Test Guide
Version 5, February 2012.
Technician Name (print): go ` ✓ Company
Technician Signature: -4* Date Y r ��!K
ApplianceTested:.k2h. d Afaa..1-t3ar _._._...... _--
Appliance Replaced: _sL��a r
Worst Case Conditions.
Spillage Duration (in seconds):
Pass _LL F
Natural Conditions:
Spillage Duration (in seconds):
_S" Carbon Monoxide (p super pillion): 17,
it Date Tested: Tgtl�
Carbon Monoxide (parts per million):
Pass Fail Date Tested:
(Nailed test requires corrections until teat passes under Natural C'onditions.)
Technician's recommendations to correct tested appliance failure:
Failed Worst Case Conditions:
I uertify 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. 1 acknowledge that I have received a
combustion appliance safety information sheet.
Owner's Name (print)
Owner's Signature
CST:rcplaccment/natural-draft/4.25.12
Date