HomeMy WebLinkAbout4900 BOARDWALK DR - SPECIAL INSPECTIONS - 7/8/2017Planning, Development & Transportation Services J p p
Community Development & Neighborhood Services
F6 281 North CoUeQe Avenue
`tCollins Fort Collins, 80522 0580
970.416.2740
1 970.224.6134- fax
lcgov com
Combustion Safety Test Compliance Form
Replacement of Natnr Draft Appliances in Existing Houses
Address: rT_! W-� t".y""—r '��.J�'' Permit Number) ? ?t�`i ���?
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
Version , February 2012.
Technician Name (print): I Company ja(M&Yty j ✓V,-am eCO,
Technician Signature: Date
—' ,
Appliance Tested:
Appliance Replaced: ! ( II ` ce [ C t 61
Worst Case Conditions: Q
Spillage Duration (in seconds): / D Carbon Monoxide (parts per million): l U
Pass Fail Date Tested: /
Natural Conditions:
Spillage DurationAn seconds): Carbon Monoxide (parts per million): e_
Pass _-k_ Fail Date Tested: :71AS // :7
(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-dmft/4.25.12