HomeMy WebLinkAbout6351 Compton Rd - Special Inspections/Combustion Safety - 07/11/2017Planning, Development & Transportation Services
CI$y O� Community Development& Neighborhood Services
Fort
281 North College Avenue
I�qy►t Collin 9 O. 16.27Box 0
v1F�o��� Fort Collins, CO 80522 0580
970.418.2740
970 224 6134- fax
fcgov.com
Combustion Safety Test Compliance Form
Replacement of Natural Draft Appliances in Existing Houses
Home Owners Name: -q _T W Q ,Q Y Permit Number �00_)
Address:�_[J�_%� Tele:
Licensed Contractor:
I hereby attest that I have performed the following Combustion Safety Test in accordance with Fort
Collins Combustion Safety Test Guide Version 5, February 2012.
Company Name: Allen Service License Number: MP-4
Technician Name (print): Date:
Technician Signature: Tele:
Appliance Tested: Model #: P X '�—
Appliance Re$taced: ' N\ A�C� Model #:a 0 _
STEP 1: W. rst Case Conditions Test
SpillageB c draft Duration (in seconds): " Carbon Monoxide (parts per million):
Pass
Fail (Technician must test under Natrtral Conditions if "Failed '}
Technician 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 Natrfral Conditions.)
STEP 3: Horne Owner Signature
I certify that I am the legal pwn"he above listed pIRRjrty.. -:7-_
Owner's Name (print) J
Owner's Signature — I�L
Date X /- // -
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.fegov.com/building/greenclasses.pbp
New form 3-16-2016