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HomeMy WebLinkAbout4900 E BOARDWALK DR - SPECIAL INSPECTIONS - 8/25/2014&� ,4; Community Deveycn-?enz a� 281 N. Coiie�c:''v F6rt Collins FPO Box 580 �-�Fort Collins, CC 970.416.2740 970.224.6134 (tax) fcgov.com/deve/opment Combustion Safety Test Compliance Form Replacement of Natural Draft Appliances in Existing Houses Address: ?Xac3wak C _ ,- <' I I ttS Cm - $oS�s Permit #: ,Q / S`c7 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 N.ame (print):C S►au,. Company .AcS1ow LJL 6-- Technician Signature: l rtPf _1��'l Date Appliance Tested: n8 L„4-t.e-s �Nfq+ec- Appliance Replaced: f, -be-c- ysaei� Worst Case Conditions: Spillage Duration (in seconds): Carbon Monoxide (parts per million): Pass % Fail Natural Conditions: Spillage Duration (in seconds): Pass Fail Date Tested: 3-2S j y 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. ©-,�ne-'s X ame (.print) O--ner-s anire � c-:- ,;az2men Date