HomeMy WebLinkAbout600 COWAN ST - SPECIAL INSPECTIONS - 10/14/2014Planning, Development & Transportation Services
City ®f
Fort Collins
Community Development & Neighborhood Services
281 North College Avenue
P.O. Box 580
Fort Collins, CO 80522.0580
970.416.2740
970.224.8134- fax
fcgov.com
Combustion Safety Test Compliance Form
Replacement of Natural Draft Appliances in Existing Houses
Address: O �!1' �) �t'1 G'-1— Permit Number:
Approved Agency: II \ l
Technician Name (print): 1.� 1'i( Company l/�,1��
Technician Signature:
—r�-=-- Date
Appliance Tested: ,A)c AP/
Appliance Replaced: 'Wrl fez V\PG
Worst Case Conditions:
Spillage Duration (in seconds): (p Carbon Monoxide (parts per million): lv ��
Pass X Fail Date Tested:
(Failed test requires owner's signature acknowledging results.)
Natural. Conditions:
Carbon Monoxide (parts per million):
Spillage Duration (in seconds): I,
Pass %ate 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