HomeMy WebLinkAbout630 SMITH ST - SPECIAL INSPECTIONS - 3/23/2017Planning, Development & Transportation Services
Fort Collins
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Commurtlty Development & Neighborhood Services
281 North College Avenue
P.O. -Box 580
Fort Collins, CO 80522.0580
976.416.2740
970.224.6134- fax
/cgov.com
Combustion Safety Test Compliance Form
Replacement of Natural Draft Appliances in Existing Houses
Address: 44^ cS f' Permit Number:
Approved Agency:
Technician Name (print):
Technician Signature:
Appliance Tested:
Appliance Replaced: A
Worst Case Conditions:
Spillage Duration (in seconds):
Pass Fail
(Fat ed test req i i i
Natural Conditions:
Spillage Duration (in seconds):
Pass Fa I
err-Jp'rr Company
Date
9-16 40ZD5-0
d Carbon Monoxide (parts per million): M-ApN
Date Tested:
owner's signature acknowledging results.)
Carbon Monoxide (parts per million):
Date Tested:
(Failed test requires corrections until test passes under Natural Condition..)
Technician's recommendations 110 correct tested appliance failure:
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 ap 3liance safety information sheet.
Owner's Name (pri
Owner's Signature
e