HomeMy WebLinkAbout609 JUNIPER LN - SPECIAL INSPECTIONS - 6/6/2015Planning, Development & Transportation Services
City,
Community Development & Neighborhood Services
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281 North College Avenue
P.O. Box 500
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Fort Collins, CO 805220580
970.416.2740
970.224.6134-fax
kpv com
Combustion Safety Test Compliance Form
Replacement of Natural Draft Appliances in Existing Houses �(
Address: k 06 7U4 -og ek. Permit Number. L�
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
(r- Version 5, February2012. CAL -
Technician
Name (print): �� �l T Company Technician Signature: Date 6-6-
6'
Appliance Tested:
Appliance Replaced:
Worst Case Conditions: ;LOON
Spillage Duration (in second 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:replacemcnt/natural-&aft/4 25.12
Date