HomeMy WebLinkAbout4900 BOARDWALK DR - SPECIAL INSPECTIONS - 8/7/2014F6Collinsrt
Community Development
281 N. College Ave.
PO Box 580
Fort Collins, CO 80522
970.416.2740
970.224.6134 (fax)
kgov.com/development
Combustion Safety Test Compliance Form
Replacement of Natural Draft Appliances in Existing Houses
Address: ggoy to- gos-;tr Permit #:
Approved Agency: 1"'109
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.
TechnicianName(print):Ar'Qoghen SjgS. Company 411C' low L
Technician Signature: / iP/1, a, Date '? 7-1 A
Appliance Tested: �
Appliance Replaced: �kd't Wct-1:� kea-Lew-'
Worst Case Conditions:
Spillage Duration (in seconds):_ Carbon Monoxide (parts per million):
Pass Fail Date Tested:
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