HomeMy WebLinkAbout4900 BOARDWALK DR - SPECIAL INSPECTIONS - 8/1/2017I
4
OT
.,Cothns
F \�
Community Development
281 N. Coflege Ave.
PO Box 580
Fort Collins. Co 80522
970.4182740
970.224.6134 (fax)
tcgav can/developnw4
Combustion Safety Test Compliance Form
Rgftcmmt of natural Draft Appliances in Existing Houses
Address: �� �r Permit # 1;7 ba'l5Z !
Approved Agency:
I herebyattest that I have performed the folly perf wing Combustion Safety Ted in accordance with
Fort Collins Combustion Safety Test Guide Version S, February 2012.
TechnicianName• (pint): ALCS 11/l �(, , �/. Company Q/,., , 5e r e cglc/ke- J
Technician Signature:�Dated-/-/�
Appliance Tested:
Appliance Replaced: I le,
Worst Case Conditions:
Spillage Duration (in seconds): _ 12 Carlson Monoxide (parts per million):
Pass Fail Date Tested:
Natural Conditions:
Spillage Dutatiom (ih seconds): Carbon Monoxide (parts per million):
Pass ✓ Fail Date Tested: �(— �-
(Failed tent re obw cmremoRs snot test pawn under Natural Censfions)
Technician's recommendations to correct tested appliance failure:
Failed Worst Case Conditions:
I "certify that I am the legal mvner of the above listed property and hereby acknowledge that my appliance
has failed a Combustion Safety Tess under worst cm conditions. I acknowledge that I have received a
combustion appliance safety information sheet.
Owner's Dame (print)
Owner's Signature
CST.25.12
Date