HomeMy WebLinkAbout635 S WHITCOMB ST - SPECIAL INSPECTIONS - 9/7/2016IgQq b�
City of Community Development
6rt ®lPO N. Box College Ave.
PO Box 580
Flins� Fort Collins, CO 80522
/ 970.416.274o
970.224.6134 (tax)
kgov. com/de ve/opment
Combustion Safety Test Compliance Form
Replacement of Natural Draft Appliances in Existing Houses
Address: ln-J % S �� �p Permit #: ?\�Acjala
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): h°l • Company :; 'e V �QQ�. p p r
Technician Signature: Date Q - 7�/G
Appliance Tested: 4 �-� t►,.�
Appliance Replaced:o;
—leL,
Worst Case Conditions:
Spillage Duration (in seconds):. c3 0
Pass V- Fail
Carbon Monoxide (parts per million):
Date Tested:
Natural Conditions:
Spillage Duration (in seconds): Carbon Monoxide (parts per million):
Pass Fail 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
CST: replacement/natural-dra8/4.25.12
Date