HomeMy WebLinkAbout1550 Blue Spruce Dr - Special Inspections/Combustion Safety - 05/04/2017May 04 1710:15a Hahn plumbing
970-493-5325 p.2
Planning, Development & Transportation Services
Community Development & Neighborhood Services
>: "• '•� 281 North College Avenue
Collins P.O. Box �0
Fort CotBns, CO 805220580
•.�yam_ 970.4162740
970224.6134- fax
kgov cam
Combustion Safety Test Compliance Form
Replacement of Natural Draft Appliances in Existing Houses
Home Owners Name:
it Number: 15
Tele:
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: 1 License Number: M?-15
Technician Name (print): `7� q- Date: G -64 —1
TechnicianSigna Tele:c
Appliance Tested: Model #:
Appliance Replaced:
Model #:
STEP 1: Worst Case Conditions Test
SpilWeBackdraft Duration (in seconds): Carbon Monoxide (parts per million): _
Pass __X, Fail (Technician must test under 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 famed 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.comfbuiilding/gremelasses.php