HomeMy WebLinkAbout1414 Sheep Creek Ct - Special Inspections/Combustion Safety - 12/01/2016err-:,_
Planning, Development & Transportation Services
r
City O2 Community Development a Neighborhood Services
1i� 281 North Coll enue
F6r} Collins P.O�Bo r%8CO
` Col. ris 'CO 80522 0580
� 970 416:2740
970 224 6134- fax
fcgov corn
Combustion Safety Test Compliance Form
Replacement of Natural Draft Appliances in Existing Houses
Home Owners Name: a 4,�-4 � en v,A 4 Z Permit Number: 4 7 ZW
Address: Jai I (--r '� tL"41 C4/ Tele 9 7 0 �9' C. 2
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: Allen Service
License Number: MP-4
t Technician Name (print): Q i%p� /.� Date:
Technician Si ature: gn Lti'/� Tele: C / i 6/
Appliance Tested: Iva, 4-0,c - Model #: C-7S b -412fif `i o o
Appliance Replaced: Model
STEP 1: Worst Case Conditions Test
SpillageBackdraft Duration (in seconds).- Carbon Monoxide (parts per million):
Pass Fail (Technician must 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): 0
Pass Fail
(Failed test requires corrections until test passes tinder 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
New form 3-16-2016