HomeMy WebLinkAbout4900 E BOARDWALK DR - SPECIAL INSPECTIONS - 10/2/2015Ilk= a r J Community Development
1 Y u 281 N. College Ave.
F6ft Collins PO Box580
Fort Collins, CO 80522
970.416.2740
970.224.6134 (fax)
fcgo v. com/development
Combustion Safety Test Compliance Form
Replacement of Natural Draft Appliances in Existing Houses
Address: 4(j da 'Dr- U.n: -►- Permit #: l S D
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 l-eK +A" nSo n Company f4 -,r Fi
Technician Signature: Date
Appliance Tested: A - D - S,, f l e,--f c_ -
Appliance Replaced: -P4 de-, 1�&z_-
Worst Case Conditions:
Spillage Duration (in seconds): a` Carbon Monoxide (parts per million):
Pass !/ Fail Date Tested: /C)'- � — 15
Natural Conditions:
Spillage Duration (in seconds): 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.
0%%rner's \ame (print)
Signature
CST:replacemenv'iiatural-drafv4.25.12
Date