HomeMy WebLinkAbout602 PETERSON ST - SPECIAL INSPECTIONS - 5/17/2017Community Development
281 N. College Ave.
PO Box 580
Fort Collins, CO 80522
970.416.2740
970.224.6134 (fax)
fcgov. coMde veto pmen t
Combustion Safety Test Compliance Form
Replacement of Natural Draft Appliances in Existing Houses
Address:. Permit #: 5 i
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): LC45e,,/ 1-I, j i Company
Technician Signature: C� , ,�i�', Date
Appliance Tested:
Appliance Replaced:
Worst Case Conditions:
Spillage Duration (in seconds): o I Z Carbon Monoxide (parts per million):%
Pass K Fail Date Tested:
Natural Conditions:
Spillage Duration (in seconds)
Pass Fail
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 Date
CST:replacement/natural-draR/4.25.12