HomeMy WebLinkAbout4900 E BOARDWALK DR - SPECIAL INSPECTIONS - 12/22/2014Community Development
281 N. College Ave.
, PO Box 580
'` # Fort Collins, CO 80522
Coins
970.416.2740
970.224.6134 (fax)
fcgov. com/development
Combustion Safety Test Compliance Form
Replacement of Natural Draft Appliances in Existing Houses
Address: WOO as°f iaeL -mil"x..&_ ��i'��'� Permit #: 13 / 5_19 7 ejo
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): Mario W�,'A' fz'+ idk Company AY Floukl)
Technician Signature: ��`�—�. - Date
Appliance Tested:
Appliance Replaced:
Worst Case Conditions:
Spillage Duration (in seconds)
Pass X Fail
Natural Conditions:
Spillage Duration (in seconds):
t14-' Carbon Monoxide (parts per million):
Date Tested:T t"
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 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
CST: replacement/natural-draft/4.25.12
Date