HomeMy WebLinkAbout4900 BOARDWALK DR - SPECIAL INSPECTIONS - 6/17/2014City of
F6rt Collins
Community Development
281 N. College Ave.
PO Box 580
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: 4 q/20 ` [)a _�wQl K �`it/ �.� 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):Si4iS Company k r S-joL. Ltic
Technician Signature:fU2,1 Date 6-»-1 t.t
Appliance Tested: P o�b W q+ec IAec & e t--
Appliance Replaced: �o1L wajDr
Worst Case Conditions:
Spillage Duration (in seconds): o20 Carbon Monoxide (parts per million):
Pass' Fail Date Tested: 6 — (? —I 4
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