HomeMy WebLinkAbout1550 Blue Spruce Dr - Special Inspections/Combustion Safety - 07/10/2017N )-
Manning, lDevelopment % Transportation Services
Ctn'• Of Community Developments Neighborhood Services
ity 281 North College Avenue
Fort Collins P.O. Box580
Fort Collins, CO 805220580
` 070.416.2740
970.224.6134-rax
fcgovcom
Combustion Safety Test Compliance Form
Replacement of Natural Draft Appliances in Existing Houses
Home Owners Name: 4. U 1 Imo,,_ Permit Number P)0 - ,- 0
Address: �� �u —�S,o r, �,L �o Tele: Lim
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: Rhnr ,Idol License Number. MP-15
Technician Name (print): �•i1 Date: �7- (017
Technician Signature: Tele: g] O- `l$ If �r�g
Appliance Tested: `` Model #
Appliance Replaced: wo,, 1 Peo,>�- Model k
STEP 1: Worst Case Conditions Test
SPUlageJBackdra:ft Duration (in seconds): 1 Carbon Monoxide (parts per million): kS
Pass � 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: Dome 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 aclmowledge that I have received a combustion appliance safety
information sheet (initial)
Further information can be obtained at www.fcgov.com/building/greenclasses.php