HomeMy WebLinkAbout4807 CREST RD - SPECIAL INSPECTIONS - 12/9/2015MAR-11-2016 12:16PM FROM-
9704848354 T-590 P.001/001 F-583
City of
F6rt Collins
Planning, Development & Transportation Services
Community Development & Neighborhood Services
281 North College Avenue
P.O. Box 580
Fort Collins, CO 80522.0580
970.416.2740
970.224.6134- fax
fegov.c*M
Combustion Safety Test Compliance Form
Replacement of Natural Draft Appliances in Existing Houses
Address; R' 4 Permit Number:
Approved Agency:
I hereby attest that I have been trained as an Approved Agency and have performed the following
Combustion Safety Test in accordance with port Collins Combustion Safety Test Guide
Versi n ,February 2012.
Technician Name (print):AL
, C Company
Technician Signature: Date ��j -I
Appliance Tested:
Appliance Replaced;..�nra�af K
Worst Case Conditions:
Spillage Duration (in seconds): Carbon Monoxide (parts er Ilion):
Pass Fail Date Tested: i
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:
Failed Worst Case Conditions:
I certify that l 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
CST:replaccment/natural-draft/4.25.12