HomeMy WebLinkAbout500 Apple Blossom Ln - Special Inspections/Combustion Safety - 06/30/2016ND
yft pw� + go
N r
Jvffiftja�. Development $ Transportstjon SOrAae
Community Devoiopment & NeVftrhood
281 North CaleW Avenue Soa�ticee
Ifins P.Q. Box 58o
Fort Collins, Co 80522.0
970.416.2740 r It
970.224.6134- Fax --`•
f6gov-Mm
Combustion Safety Test Compliance Form
Replacement of Natural Draft Appliances in Existing Houses
Home Owners Name: 9 I �0 `% J04-
— � ca.r k A ��J � 5 ,.� Permit Number:
Address: , c 0 leAl.,,
Tele:
Licensed Contractor: rr
I hereby attest that I have performed the following Combustion Safety Test in accordance with Fort
Collins Combustion Safety Test Guide Version 5, Februaiy 2012.
Company Name: Allen Service License Number: MP-4
Technician Name (print): = '�, � -4.i' Date: 6 - 32 -
Technician Signature: Tele:
Appliance Tested: ,�'�,� Model # : 0-1 IV-T ---T O
Appliance Replaced: goo Ae'- Model
STEP 1: Worst Case Conditions Test
SpillageBackdraft Duration (in seconds): Carbon Monoxide (parts per million): j .3
Pass Fail (Technician lilust test. ander Natural Conditions if "Failed ")
Tecluiician's recotrsnendaiions to correct tcstc;d appliance failure:
STEP 2: Natural Conditions Test
Spill age/Backdra ft Duration (in sccon s}: :±_1realat. _00Ps,d,.icle (Park per million):
Pass Fail
(Failed test requires carrections unfit te1t passev under Natxtr(rl Crladitioll.s.)
STEP 3: Home Owner Signature
I certify that I am the legal owner of'the aboxc listed propeny.
Owner's Name (print)
Owner's Signature
Date
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