HomeMy WebLinkAbout5018 Switchgrass Ct - Special Inspections/Combustion Safety - 07/11/2017Planning, Development & Transportation Services
Community Do% elopment & Neighborhood Services
281 North College.Avenue
P_O Box 580
Fort Collins. CO 80522 0580
970.416,2740
970 224 6134- fax
tcgov corn
Combustion Safety Test Compliance Form
Replacement of Natural Draft Appliances in Existing Houses
Home Owners Name- e<, c.40—t- (,)t ((e A_6c Permit Number.
Address. � 4ct, s _�_ C_/_T,� Tele x( 7b 3e6 S 7 ?g
Licensed Contractor:
I hereby attest that I have performed the following Combustion Safety Test in accordance with Fort
Collis Combustion Safety Test Guide Version 5, February 2012.
Company Name- Allen Service License Number. MP-4
Technician Name (print): d5 4A 4:. a) ' 6 Date 7, /!;, Ll2
Technician Signature Tele. (-(,fc{ �,ec(
Appliance Tested- /), ,�, l LModel #. t'75 VcO
Appliance Replaced: W.4-b, C4z*,L, Model #.
STEP 1: Worst Case Conditions Test
SpillageBackdraft Duration (m seconds) _ Carbon Monoxide (parts per million):
Pass Fail (Technician urnst 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 (pails per million)
Pass Fail
(Failed test requires corrections until test passes under Aratur•al Conditions.)
STEP 3: Home Owner Signature
I certify that I am the legal owner of the above listed pi operty
Owner's Name (print)
Owner's Signature
Date
In the event that my appliance has failed a Combustion Safety Test under Nti orst-case
conditions, I hereby acknowledge that I have received a combustion appliance safety
information sheet (initial)
Furthei information can be obtained at www.fcgov convbuildinglgreenclasses php
New form 3-16-2016