HomeMy WebLinkAbout4900 E BOARDWALK DR - SPECIAL INSPECTIONS - 4/22/2015Community°.__.c-=-..
_ s a' 281 N. Cc!:c:
Fort Collins P°B°x�_ .
___-
Fort Collins. C— -
!� 970.416.2740
970.224.6134 (sax;
fcgov. com/develop,,,
Combustion Safety 'Pest Compliance Form
Replacement of Natural Draft Appliances in Existing Houses
Address: 49 0 0 &_>Ak WA L K Y L4 2I)fJ Permit #: 8 lS-0 7 V 6
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 : �., ��,;,�C c+ri Company li e L C% to"
(P ) !i L..�f.! r
Technician Signature: ,�- _FJ�� Date-AZDate12f-AZ Z
Appliance Tested:
Appliance Replaced: 4-14
Worst Case Conditions:
Spillage Duration (in seconds) -
Pass Fail
Natural Conditions:
Spillage Duration (in seconds)
Pass Fail
Carbon Monoxide (parts per million):
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 Name (print)
O%vne-'s Si _-