HomeMy WebLinkAbout2225 Creekwood Dr - Special Inspections/Combustion Safety - 06/30/2016l Planning, Development Si Transportation Services
C1ty 07 -I P. Community Development & Neighborhood Services
North College Avenue
P.O Box 580
F0rt 011i ns J
Fort Collins COS 522 0580
. 970.416.2740
970.224 6134- fax
kgov com
Combustion Safety Test Compliance Form
Replacement of Natural Draft Appliances in Existing Houses
Home Owners Name: DENNIS PEDERSEN Permit Number: B1602549
Address: ?')75 CRF& KWQ0 .11Ns Rnsz; Tele: 970-221-0096
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:
Technician Name (print): R P Date:
Technician Signature:
H-837
6/30/2016
Tele: 970-273-8873
Appliance Tested: WATER HEATER Model #:
Appliance Replaced: FURNACE Model #: EL195UH09OXE48C
STEP 1: Worst Case Conditions Test
SpillageBackdraR Duration (in seconds): Carbon Monoxide (parts per million):
Pas (Technician Hurst test tinder Natural Conditions if "Failed')
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)
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
information sheet. (initial)
Further information can be obtained at www.fcgov.com/building/greenclasses.php