HomeMy WebLinkAbout1418 CACTUS CT - SPECIAL INSPECTIONS - 6/8/2015JUN/25/2015/THU 10:59 AM FAX No, P,002
T Planning, Development & Transportation Services
community Development & Neighborhood Services
�-. City ®f 2at North College Avenue
Frt P.O. Box 580
liColl' ns
:J Fort Collins, CO 80522.0580
970,416.2740
970224.6134- fex
kgov.wm
Combustion Safety Test Compliance Form
Replacement of Natural Draft Appliances in ]Existing Houses
Address: 1q 1$ eaelE o C � Permit Number: 61y Q qM 4
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. y� ,�/� j
Technician Name (p ' Company (tea1Ocal lk14a 1► AarliCd1
Technician Signature: pate (/ $
Appliance Tested:
_Appliance Replaced: ,...... -- ....... _ ..........
Worst Case Conditions:
Spillage Duration (in seconds): Carbon, Monoxide (parts per million):
Pass V/ Fail Date Tested: C
Natural Conditions:
Spillage Duration (in seconds): Carbon Monoxide (parts per million):
Pass N/ Fail Date Tested: fg
(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 nay 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