HomeMy WebLinkAbout4436 WARBLER DR - SPECIAL INSPECTIONS - 6/15/2015i
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Fort Collins
Planning, Development & Transportation Services
Community Development 3 Neighborhood Services
281 North College Avenue
P.O. Box 580
Fort Collins, CO 80522.0580
970.416.2740
970.224.6134- fax
fcgov.com
Combustion Safety Test Compliance Form
Replacement oiNatural Draft Appliances in Existing Houses
Address: t—/C3G (,,�
Approved Agency:
Technician Name (print)
Technician Signature:
Appliance Tested: I
Appliance Replaced: t JA
Worst Case Conditions:
Gam- pr- .
Permit Number: � 1.5D.6,0 q
_ Date �5 s
Spillage Duration (in seconds): qU Carbon Monoxide (parts per million):
Pass /on
Fa 1 Date Tested: Z S
(Failed test req#ires owner's signature acknowledging results.)
Natural Conditions:
i
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 Io 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 ap liance safety information sheet.
Owner's Name (print)
Owner's Signature
Date
A