HomeMy WebLinkAbout6836 TIMPAS DR - SPECIAL INSPECTIONS - 6/30/2016From:
07/07/2016 11:20 0337 P.002
City of
F6rt Colfins 9�
Planning, Development & Transportation Services
Community Development & Neighborhood Services
281 North College Avenue
P.Q. Box 580
Fort Collins. CO 80522.0580
970.416.2740
970.224.6134-fax
fcgov.com
Combustion Safety Test Compliance Form
Replacement of Natural Draft Appliances in Existing Houses
Address: Permit Number: �otp
Approved Agency:
I hereby attest that I have been trained as an Approved Agency and have pe or sled the following
Combustion Safety Test in accordant wit Fort Collins Combustion fety Test Guide
Versi 5- bruary 2012.
Technician Name (print): U�..� Company �, ,
Technician Signature:
Appliance Tested: A/
Appliance Replaced:(�.��1r"!
Date ka/3f
Worst Case Conditions:
Spillage Duration (in seconds): 3 Carbon Monoxide ( arts per illion):
Pass V Fail Date Tested:
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 recomm
to correct wed appliance failure:
Failed Worst Case Conditions:
1 certify that 1 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 N
Owner's S
CST: replacemenifnatural-draft/4.25.12