HomeMy WebLinkAbout4900 E BOARDWALK DR - SPECIAL INSPECTIONS - 9/26/2014Community Development
-1 L If ' L 281 N. College Ave.
Fort Collins P°B°x�$°
Fort Collins, CO 80-527
970.416.2740
970.224.6134 (fax)
fcgov. com/development
Combustion Safety Test Compliance Form
Replacement of Natural Draft Appliances in Existing Houses
Address: 410 e cd�..u►!L c��;Ue W-01 JI.&Ili ns C,_ go3, s Permit #: R / �D 7 A/3
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): pheC 5- aS Company ,/4 , r- �)ow LU-
Technician. Signature: ,Aj �,t'�-Gem Date
Appliance Tested:
Appliance Replaced: �Ao-�-, Lqqt�*r- `m-bes:
Worst Case Conditions:
Spillage Duration (in seconds): ap
Pass r;,L. Fail
Natural Conditions:
Spillage Duration (in seconds)
Pass Fail
Carbon Monoxide (parts per million): 14
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 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 1Tame (print)
Owner's Signature
CST:replaczment nai< rzI-draft' I.25.12
Date