HomeMy WebLinkAbout1419 Sioux Blvd - Special Inspections/Combustion Safety - 04/22/20179704821803 Mountain Sage Community Sch
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Planning, Development & Transportation Services
Cat Of Community Development & Neighborhood services
Cityof
^ 281 North College Avenue
Fort Collins U 1 Fort Colll se CO 80522 0580
970 416 2740
970 224 6134- tax
`. fcgov cam
Combustion Safety Test Compliance Form
Replacement of Natural Draft Applwnces in Existing Houses
Home Owners Name �� f Alm% 1�CxLZ Permit Number 16 o 3 &U� 3,'
Address 4�)Tele
Licensed Contractor•
I hereby attest that I have performed the following Combustion Safety Test in accordance with Fort
Collins Combustion Safety Test Guide Verson S, February 2012
LCompany Name vYit License Number /.
Technician Name (print) u i � Date. Y% Z Z < / 7
Technician Signature & Tele
Appliance Tested 4fJi4 A--'-,4e 1-k-W)67� Model # X6 O 7-0 9 I -I yDUO
Appliance Replaced -
Model #
STEP 1: Worst Case Conditions Test
Spillage/Backdmft Duration (in seconds) � Carbon Monoxide (parts per million).
Pass Fail (Technician must test under Natural Conditions if "Failed')
Technician's recommendations to correct tested appliance failure
STEP 2: Natural Conditions Test
Spillage/Backdraft 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) R`/AI J MG lf'�
Owner's Signature
Date Apr, i Z2, Zai
In the event that my appliance hffs 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