HomeMy WebLinkAbout615 W LAKE ST - SPECIAL INSPECTIONS - 6/19/2015Jun 19 1502:18p Hahn plumbing
970-493-5325 p.2
Planning, Development & Transportation Services,
City of Community Davefopment & Neighborhood Services
Fort Collinsrth College Avenue
P.O.P.
P.O. Box 590
Fora Collins, CO 80522.058D
970.416.274o
970.224.6134-fax
rcgov corn
Combustion Safety Test Compliance Form
Replacement of Natural Draft Appliances in Existing Houses
Address: L2 I '5� (AD `Lp Permit Number: 91 SOq -] 56
Approved Agency:
Technician Name
Technician Signature
Appliance Tested:
Appliance Replaced: ( cAlex
Companyt : �5
Date
Worst Case Conditions:
Spillage Duration (in \se`conds): Carbon Monoxide (parts per million): 3
Pass X Fail Date Tested: ( - n r),iCj
(Failed test requires owner's signature acknowledging results.)
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:
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 Date