HomeMy WebLinkAbout600 Saint Michaels Dr - Special Inspections/Combustion Safety - 07/10/2017City
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Flirt Cot tans
Planning, Development & Transportation Services
Community Development & Neighborhood Services
281 Norlh CoiNge Avenue
P O Box 580
Fort Collins CO 80522 0580
970 416 2740
970 221 0134. lax
lcgov corn
Combustion Safety Test Compliance Form
Replacement of Natural Draft Appliances in Existing (louses
Home Owners Name PARAM MAHAL �_ _
Permit Num&11 __
ber
Address 600 ST=MICHAELS DR Tele 970-226-0620
Licensed Contractor.
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- NORTHERN COLORADO AIR INC License Number H-837 `
Technician Name (print) SCOTT ZIEGLER Date -
Technician Signature _
Appliance Tested. WATji PHEAil R Model It
Appliance Replaced- WATER HEATER (1) Model i! RG240T6N
07/10/2017
Tele 970-223-8873
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 to correct tested appliance I'ailure-
STEP 2: Natural Conditions Test
Spillage/Backdrali Duration (in seconds) Carbon Monoxide (parts per million).
Pass _ Fail
(Failed test requires corrections until test passes under Natural Conditions.)
STEP 3: Ilome 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, 1 hereby acknowledge that I have received a combustion appliance safety
information sheet (initial)
Further information can be obtained at%vww.fcgov.com/building/greencIasses php