HomeMy WebLinkAbout4206 Monmouth Ct - Special Inspections/Combustion Safety - 07/31/2017Aug 02 1707 36a Hahn plumbing 970-493-5325 p.2
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Community6evelo}merdP-Weighbo;hoa Services
- - 281 Noeh Cdlege Avenue
"T � �� f iF �� K= P_O. Box 580
Fort Colons, CO a0522.0590
970.ejG,274C
970.224 6134- i=
fcgm cont
Combustion Safety Test Compliance Form
Replacement of Natural Draft Appliances in Ei1sting Houses
Home Owners Name: ,� t,.e-- M o r, Permit Number. ` - (- 0` t8- 0
Tele: 6t?0 -2 14
Licensed Contractor: -`--A-C>LL) J-C--
I hereby attest that I have perforated the following Combustion Safety Test in accordance with Fort
Collins Combustion Safety Test Guide Version 5, February 2012.
Company Nama: t'S(1 ,n I tI.46Mn0 d! iC\ \[tO� License Number:
Technician Name (print): C- W-a Date: , 1 `/
Technician Signature: _ i Tele:
Appliance Tested: O c.-N-e� R Q-e4� Model #:
Appliance Replaced: 4 e-c,-k-r- Model#:
STEP 1: Worst Case Conditions Test
Spiilage/Backdraft Duration (in seconds): Carbon Monoxide (pamper million):1_
Pass Fail (Technician muse test under Natural Condidons 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 anti? testpasses under Natural Condiions.)
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/gTeenclasses.php