HomeMy WebLinkAbout6227 CLYMER CIR - SPECIAL INSPECTIONS - 12/15/2016Cityvf
Fort GQ[LInS
Planning, Development & Transportation Services
community oevelopment & Neighborhood Servlces
281 Nosh College Avenue
P,O. Box 580
Fort Collins, CO 80522.0580
970.416.2740
970224.6134- fax
kgov.com
Combustion Safety Test Compliance Form
Replacement of Natural Draft Appliances in E3dsting Houses
to j ex j�j&i-4 d1 rc/ Permit Number:
Address: ,�"�
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
'technician Name (print),
Technician Signature:
Appliance Tested: A>�
Appliance Replaced:
Worst Case Conditions:
'Spillage Duration (in seconds):: Carbon Monoxide (p per llion):
Pass ,l Rail Date Tested: /t2
Natural Conditions:
Spillage Duration (in seconds): �/4 S&arbon Monoxide (parts r nu lion):
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 ackn ledge 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/nattwW-drdV4.25.12