HomeMy WebLinkAbout913 CHEYENNE DR - SPECIAL INSPECTIONS - 7/8/2015Jul 08 15 03:21 p Hahn plumbing
970-493-5325 p.2
Fort Collins
Planning, Development & Transportation Services
Community Development & Neighborhood Services
281 North College Avenue
P.O. Box 580
Fort Collins. CO 80622.0580
970.416.2740
970.224.6134- fax
fcgov.com
Combustion Safety Test Compliance Form
Replacement of Natural Draft Appliances in Existing Houses
�+ 51 SO 5Z I �-
Address: 1 CKe Permit Number B 150 $ 7. Z I
Approved Agency: f
Technician Name (printo� c-tc Compan n T f via.
Technician Signature:
Appliance Tested L,6- �7 ���
Appliance Replaced: � QevA er- hAbiVeZ 21
Date
Worst Case Conditions:
Spillage Duration (in seconds): Carbon Monoxide (parts per million): 77_
Pass -E Fail Date Tested: r"I'3 "
(Failed test requires owner's signature acknowledging results.)
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:
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