HomeMy WebLinkAbout3425 Oregon Trl - Special Inspections/Combustion Safety - 11/22/2016From
06/14/2017 02.33 0632 P 001/001
Planning, Development & Transportation Services
Clt Y f�f Community Development s Neighborhood Services
281 North College Avenue
CollinsCF rt Box 580
Flirt ` lJ�', ` oA Collins. CO 80522 0580
970 416 2740
970 224 6134•fax
fcgov com
Combustion Safety Test Compliance Form
Replacement of Natural Draft Appliances in Existing Houses
Home Owners Name Permit Ntunber\\005��L147
Address 3R-6S bte Fs!K _�,i \q 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 Namer r rL-\jr&UJJ.A li.,( License Number -%3S
Technician Name (print) �a-TkAOIN A 1.7 Date ��� �\b
Technician Signature -- Tele3-�J�
Appliance Tested Model #
Appliance Replaced Model #
STEP 1: Worst Case Conditions Test Q
SpillageB�
ackdraft Duration (in seconds) 5 Carbon Monoxide (parts per million) jag
Pass Fail (Technician must test under Natural Conditions ij "Failed' j
Technician's recommendations to correct tested appliance failure
STEP 2: Natural Conditions Test
SpillageBackdraft Duration (in seconds) Carbon Monoxide (parts per million)
Pass A_ 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 failed a Combustion Safety Test under worst -case
conditions, I hereby acknowledge that 1 have received a combustion appliance safety
information sheet (initial)
Further information can be obtained at www fcgov com/building/greenclasses php