HomeMy WebLinkAbout605 S MELDRUM ST - SPECIAL INSPECTIONS - 8/9/2016From
08/12/2016 09:50 #351 P.003
Planning, Development & Transportation Services
City o Community Development & Neighborhood Services
281 North College Avenue
Flirt lotho 1 P.O. Box 580
Fort Collins, CO 80522.0580
970.416.2740
970224.6134- fax
fcgov.com
Combustion Safety Test Compliance Form
Replacement of Natural Draft Appliances in Existing Houses
Address:. _W _ J Permit Number:
Approved Agency:
I hereby attest that I have been trained as an Approved Agency and have performed the following
Combustion Safety Test in accordance with Fort Collins Combustion Safety Test Guide
Versioft 5, F bruary 2012.
Technician Name (print):
Company � ���
Technician Signature: y Date
Appliance Tested: L/ l �_, �� rd 1 l 1 > 1 L�
Appliance Replaced: Y 0
Worst Case Conditions:
Spillage Duration (in second;):Lj Carbon Monoxide (parts per million): 12 —
Passy Fait Date Tested:
Natural Conditions:
Spillage Duration (in seconds): _ Carbon Monoxide (parts per million):
Pass Fail Date Tested:
(Failed test requires corrections until test pusses under Natural Conditions.)
Technician's recommendjpflons to correct tested appliance failure:
Failed Worst Case Conditions:
1 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 1 have received a
combustion appliance safety inforrhation sheet.
Owner's Name (print)
Owner's Signature
CST: replacement/natural-draft/4.25.12
Date