HomeMy WebLinkAbout2957 County Fair Ln - Special Inspections/Combustion Safety - 05/04/2016 (2)rl j�Ll/
Planning, Development & Transportation Services
City.
Or Community Development & Neighborhood Services
ort Coilins P.O.North College Avenue
F P.Box 580
Fort Collins, CO 80522.0680
970.416.2740 t, ' t , :,d' e : r
970.224.6134- fax ` _. E .; L .i� ;. .
fcgovxom
Combustion Safety Test Compliance Form
Replacement of Natural Draft Appliances in Existing Houses
Home Owners Name: J01-IN HOBBS Permit Number: 5
Address: 7"7 C(IIINTV FAI.INS 80528 Tele: 970-493-1307
Licensed Contractor:
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.
Company Name: NCA, INC License Number:
H-837
Technician Name (print): M GENTRUP Date: .. 5/04/2016
Technician Signatur . _ Tele: 970-223-8873
Appliance Tested: WATE ATER Model #:
Appliance Replaced: WATER HEATER Model #: RG250T6BN
STEP 1: Worst Case Conditions Test
SpillageBackdraft Duration (in seconds): Carbon Monoxide (parts per million); `
Pass/<-' Fail (Technician must test under Natural Conditions if I`Failed'j
Technician's recommendations to correct tested appliance failure:
STEP 2: Natural Conditions Test
SpillageBackdraft Duration (in seconds): Carbon Monoxide (parts per million):
Pass Fail
(Failed test requires corrections until test passes under Natural Conditions.)
STEP 3: Home Owner Signature
I certify that I am the legal owner of the above listed property.
,, � / Owner's Name (print) 6,1,1-il S 2�1-10 eB'j-
Owner's Signature
Date J�
In the event that my appliance has failed a Combustion Safety Test under worst -case
conditions, I hereby acknowledge that I have received a combustion appliance safety
information sheet. (initial)
Further information can be obtained at www.fcgov.com/building/greenclasses.php