HomeMy WebLinkAbout4913 LANGDALE CT - SPECIAL INSPECTIONS - 5/5/2016to
Community Development
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F6et Collins �� �v/ 281 N. College Ave.
PO Box 580
Fort Collins, CO 80522
970.416.2740
970.224.6134 (fax)
fcgov.com/development
Combustion Safety Test Compliance Form
Replacement of Natural Draft Appliances in Existing Houses
Address:L�> �.��y �•� i �=�— Permit #: /lv Ca Z
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): 1,-2 v l Company M _� z,,,,! 4-j - kA
Technician Signature: Date
Appliance Tested:
Appliance Replaced: Ltj I,s---
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)
Owner's Signature
CST:replacement/natural-draft/4.2 5.12
Date