HomeMy WebLinkAbout4326 MESAVIEW LN - SPECIAL INSPECTIONS - 5/13/2015City ®f Community Development
Collins PO CollegeAve.
PO Boox 580
F6rt
Fort Collins, CO 80522
970.416.2740
970.224.6134 (fax)
fcgov.com/deve/opment
Combustion Safety Test Compliance Form
Replacement of Natural Draft Appliances in Existing Houses
Address: 3� l�-e- L/ r GL Permit #:
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):; -, l�� Z Company 10/ r -�
Technician Signature: Date l
n
Appliance Tested:
Appliance Replaced:
t✓L Lc
Worst Case Conditions:
Spillage Duration (in seco s): 1 Carbon Monoxide (p rts per illion):
ass PFail Date Tested: �� S
Natural Conditions:
Spillage Duration (in seconds):
Pass Fail
Carbon Monoxide (parts per million):
Date Tested:
C
(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