HomeMy WebLinkAbout410 WAYNE ST - SPECIAL INSPECTIONS - 9/7/2015Planning, Development & Transportation Services
u.�C Community Development & Neighborhood Services
City of 281 North College Avenue
Tbirt Collins , FOColll s8CO80522.0580
970.416.2740
970.224.6134-fax
kcgov.com
i
Combus ion Safety Test Compliance Form
Replacement o Natural Draft Appliances in Existing Houses n 7 -
Address: 1-40 I,JG.lrV_ I Sk . Permit Number: 615oZ03(a
I
Approved Agency:
Technician Name (print): Nl,
Technician Signature:
Appliance Tested: We.r
Appliance Replaced: W c V-e
Worst Case Conditions:
Spillage Duration (in seconds):
Pass N
(Failed test req
Natural Conditions:
Spillage Duration (in seconds):
Pass FI
(Failed test requires c
Technician's recommendations
Company AVU, Serv:C_e
Date (N 1p Zo is
cj Carbon Monoxide (parts per million): S
it Date Tested:
fires owner's signature acknowledging results.)
Carbon Monoxide (parts per million):
Date Tested:
until test passes under Natural Conditions.)
correct tested appliance failure:
I certify that I am the legal own r of the above listed property and hereby acknowledge that my
appliance has failed a Combusti n 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 I Date