HomeMy WebLinkAbout4900 E BOARDWALK DR - SPECIAL INSPECTIONS - 12/7/2014�� �n Community Development
l' �l c 281 N. College Ave.
F ort Collins PO Box 580
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Fort Collins, CO 80522
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970.416.2740
970.224.6134 (fax)
fcgov.com/deve/0pment
Combustion Safety Test Compliance Form
Replacement of Natural Draft Appliances in Existing Houses
,ww o�� h�! S .
Address: `4-74CI i4 p-r ! C> tf Permit #:
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): 1A)IF_G A( tAA4" -V—
Technician Signature: W
Appliance Tested:
Appliance Replaced:yAMPRA tWvS471f' "
Company A i m F L u c.J
Date 1-� — `7' 1 �
Worst Case Conditions:
Spillage Duration (in seconds): S6 Carbon Monoxide (parts per million):
Pass Fail Date Tested:
Natural Conditions:
Spillage Duration (in seconds)
Pass Fail
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.
Ov,\r±er`s'Name (.print)
1, ___ _. Sf .a —cure
R_ t =-= :sal-LLMIL i,
Date