HomeMy WebLinkAbout5205 Mail Creek Ln - Special Inspections/Combustion Safety - 08/24/2017From
08/24/2017 08.08 #722 P 001/001
Planning, Development & Transportation Services
��� 1 h Community Development & Neighborhood Services
City O
[/�► 281 North College Avenue
Ort Collin, PO Box580
C
Fort Collins, CO 80522 0580
970.416 2740
224 6f 34- fax fcg a I
/cgov com o
Combustion Safety Test Compliance Form
Replacement of Natural Draft Appliances in Existing Houses
Home Owners Name: �aj�xl_ NLJ ; Permit Number: 1wowg lli. - t& S%7
Address= �AaL� Tele'at� 1\'�
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 LAX�v License Number
Technician Name (print G� a� Date: _ 2 t� V—) —
Technician Signatur Tele: — ,
Appliance Tested Model #: _ iV
&� Appliance Replaced: Model #A4.G�
STEP 1: Worst Case Conditions Test
Spillage/Backdra Duration (in seconds): Carbon Monoxide (parts per million)-
Pass Fail (Technician must test under Natural Conditions if "Failed')
Technician s recommendations tom she appliance failure:
STEP 2: Natural Conditions Test
Spillage/Backdraft Duration (in se co S Carbon Monoxide (parts per million):
Pass Fail
(Failed test requires corrections until test passes under Natural Conditions.)
STEP 3: Home Owner Signature
1 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