HomeMy WebLinkAbout4900 BOARDWALK DR - SPECIAL INSPECTIONS - 8/11/2017I.., b
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Community Development
281 N. College Ave.
PO Box 580
Fort Colihs, CO 80522
970AISM40
970.224.6134 (fax)
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Combustion Safety Test Compliance Form - -
Replacement of Natural )Draft Appliances in Existing Houses
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Address: 06 vCkcza� —bxv l ;J04 Permit
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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.
Technicians gme(print): Company An/r) / Cam•
Technician Signature: Date i/ /i i
Appliance Tested: CIO M 1 ,/ 0
Appliance Replaced:
Worst Case Conditions:
Spillage Duration (in seconds): 15�L Carbon Monoxide (parts r million):
Pass Fail Date Tested: Orr
Natural Conditions:
Spillage Duration( seconds): 5 S Z Carbon Monoxide (parts million):
Pass Fail Date Tested: 8 /, /
(Failed test requires corrections anti/ test passes under Natural CottAWom)
Technician's recommendations to correct tested appliance failure:
Failed Worst Case Conditions:
f 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
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Date