HomeMy WebLinkAbout4442 Viewpoint Ct - Special Inspections/Combustion Safety - 09/30/2016Fort
Planning,. Development & Transportation.Ser"vices
Community Development& Neighborhood Services
281 North College Avenue
P.O. Box 580
Fort Collins, CO 80522.0580
070.416.2740
970.224.6134- fax
fcgov.con?
Combustion Safety Test Compliance Form
Replacement of Natural Draft Appliances in Existing Houses
Home Owners Name- (W(rPermit Number:
k
'
Te '-/
Address: P0 I C " . 7,1 7' I
Licensed Contractor:
I hereby attest that I have.perf0imed the following Combustion Safety Test in accordance with Fort
Collins Combustion Safety Test Guide Version 5, February 2012.
Company Name: Allen Service License Number: MP-4
Technician Name (prhit).- Date:
Technician Signa
ture Tele. V
Appliance Tested: -1 Model #: YYi�. S
A Appliance Replaced: fj� 111f I(- Mod, -I.#: 1'd 0J '3 b0.
STEP 1: Worst Case CouditionsTest
Spillage/BackdrAft- Duration (in seconds): A'— Carbon Monoxide (parts. per million).:.
.Pass Y Fail (Technician must test under Natural Conditions if 'Wailed9
Technician's recoin-fiiendations. to correct tested appliance failure:
STEP2: Natural Conditions Test
Spillage/BacMraft Duration (in seconds):. Carbon Monoxide (parts per million):
V
Pass Fail
(Falleif test requires corrections until testpas-ves un(ler Alatural Conditiolis.)
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
infoi.mation sheet (initial)
Further information can be obtained at.www...fegov.cojii/buildin.&/,-,reenclasses.pbp
New form 3-16-2016