HomeMy WebLinkAbout4900 E BOARDWALK DR - SPECIAL INSPECTIONS - 9/13/2014-Community Development
,1,VY, CF1' 281 N. College Ave.
Fort Collins PO Box 580
Fort Collins, CO 80522
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,`970.416.2740
970.224.6134 (fax)
fcgov. com/developmen t
Combustion Safety- Test Compliance Form
Replacement of Natural Draft Appliances in Existing Houses
Address: %� / Permit #: % D 7
Approved Agency:
I hereby attest that I have performed the following Combustion Safety Test in accordance with
Fort Collins Combustion Safety Test Guide Version 5, February 2012..
Technician Name (print): Company �T
Technician Signature: ,._,
Date q — 1 3
Appliance Tested:
Appliance Replaced:
Worst Case Conditions:
Spillage Duration (in seconds):
Pass,-' Fail
Natural Conditions:
Spillage Duration (in seconds):
Pass Fail
Carbon Monoxide (parts per million): &7
Date Tested:
Carbon Monoxide (parts per million):
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 certif- that I am the lesal owner of the above listed property and hereby acknowledge that my appliance
^as failed a Conibustion Safety" Test under worst -case conditions. I acknowledge that I have received a
C.»rL:s_:o:_ -"C,, s_ mrormation sheet.
Date