HomeMy WebLinkAbout4900 E BOARDWALK DR - SPECIAL INSPECTIONS - 3/30/2015Community Development
ti281 N. College Ave.
PO Box 580
F6rt"Collins
� Fort Collins, CO 80522
970.416.2740
970.224.6134 (fax)
fcgov. com/development
Combustion Safety Test Compliance Form
Replacement of Natural Draft Appliances in Existing Houses
Address:ywo /3a-trCl;,-4a le */� 10.5-- Permit #: l� /,�` 7 V/(
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); A-lja4 ro Company ,At,,,- /--`/`Lt-, ttc
Technician Signature:
Appliance Tested:
Appliance Replaced: Wg. --e.,r
Date
Worst Case Conditions:
Spillage Duration (in seconds): 135' Carbon Monoxide (parts per million): l'
Pass 94- Fail
Natural Conditions:
Spillage Duration (in seconds):
Pass Fail
Date Tested: -�-�> 1 7y /i S
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 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)
Ovmer's Signature
C S T: re p 1 ac ement/n atural-draft/4.25.12
Date