HomeMy WebLinkAbout5125 Sawgrass Ct - Special Inspections/Combustion Safety - 08/04/2016Planning, Development & Transportation Services
C,�**tyy� Community Development&.Neighborhood Services
ity M 281 North College Avenue
Foitsg P.O. Boa 580
°°�� Fort Collins, CO 80522.0580
970.416.2740
'-'A 970 224.6134- rax
icgov. com
Combustion Safety 'Test Compliance Form
Replacement of Natural Draft Appliances in Existing .Houses
Home Owners Name: 7T7 0 �nL � S Permit Number:
Address: 41�-12;�— S Tele:
Licensed Contractor:
I hereby attest that I have perforrned the following Combustion Safety Test in accordance with Fort
Collins Combustion Safety Test. Guide Version 5, February 2012.
Company Name: Allen Service
License Number: M P-4
Technician Name (print): 9/b-n - V`^rDate:
T
Technician Signature: Tele:
Appliance Tested: Model #:
Appliance Replaced: l�>a'l�'� odel #:
STET' 1: Worst Case -Conditions Test
SpillageB:��Iail
Duration (in seconds): Carbon Monoxide (parts per million):
Pass .(Technician must test under Natural Cmididons if "Failedp9
Technician's recommendations to correct tested appliance failure:
STEP 2: Natural Conditions Test j
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
Irr, 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
infbn:' ation sheet. (initial)
Further information can be obtained at www.fegov.com/building/greenclasses.php
New form 3-16-2016