HomeMy WebLinkAbout664 BREWER DR - SPECIAL INSPECTIONS - 6/2/2015Planning, Development & Transportation Services
City. OI Community Development & Neighborhood services
®�� ®��'�� 281 North Box
58011ege Avenue
F P.O. Box Sao
Fort Collins, CO 80522.0580
970AI6.2740
970.224.6134-fax
Icgov.com
Combustion Safety Test Compliance Form
Replacement of Natural Draft Appliances in Existing Houses
Address: (/0(1/5'' ,�&-Ie-t®",..- Permit Number:
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.
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�b"� %4i-✓ Company a
Technician Name (print): pany 'W It
Technician Signature: ���;Kae�� Date 6
Appliance Tested:
Appliance Replace
Worst Case Conditions:
Spillage Duration (in seconds): X Carbon Monoxide (parts per million): �
Pass 7 Fail Date Tested:
Natural Conditions:
Spillage Duration (in seconds): Carbon Monoxide (parts per million):
Pass Fail 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-dratt/4.25.12
Date