HomeMy WebLinkAbout2813 Dundee Ct - Special Inspections/Combustion Safety - 09/22/2017.C.
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Planning, Development $ Transportation Services
Community Development & NeighbOdx)cd Sorvices
281 North College AvenUB
P.O. Box 580
Fort Collins, CO 80522.0580
970.416.2740
970.224.8134 fax
tgov.com
Combustion Safety Test Compliance Form
Replacement of NaturalDraftAppliance's in insisting Houses
Home Owners Name: 111 D Permit Number:
Address:—RR/3 I
Licensed Contractor:
I hereby attest that I have performed the following Combustion Safety Test in accordance with port
Collins Combustion Safety Test Guide Version 5, February 2012.
Company Name: P. S License Number.
Technician Name (print) . Date: as e
Technician Signature: Tele•
Appliance Tested: 0 • 8 Model #: R G.a ^ w o
Appliance Replaced: 6 • W Model #:
STEP 1: Worst Case Conditions' Test
Spolage/gackdraR Duration (in seconds): Carbon Monoxide (parts'per million):
Pass Fail (Technician must test under Natural Conditions f "Failed")
Technician's recommendations to correct tested appliance failure:
STEP 2: Natural Conditions Tlest
SpillageBackdraR Duration (in seconds): Carbon Monoxide.(parts per million): _
Pass Fail
(Failed test requires corrections until test passes under Natural Conditions.)
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 acimowledge that I have received a combustion appliance safety
information sheet (initial)
Further information can be obtained at www.fcgov.00m/building/greenclasses.php