HomeMy WebLinkAbout4625 BRENTON DR - SPECIAL INSPECTIONS - 7/20/2017Planning, Development & Transportation Services
City Of Community Development & Neighborhood Services
Fort Collins P.O.North College Avenue
F P.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
J) Address: �I n 4 Permit Number: B I %D 314 S
Approved Agency: t Vi &S � 7
1 hereby attest that I have been trained as an ApprovedVge'eand have performed the following
Combustion Safety Test in accordance with Fort Collins Combustion Safety Test Guide
Version 5, February 2012.
Technician Name (print):
Technician Signature:
Appliance Tested:
Appliance Replaced:
_company
aj!--� Date
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:
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 1 have received a
combustion appliance safety information sheet.
Owner's Name (print)
Owner's Signature
CST: replacement/natural-draft/4.25.12
Date
I JA