HomeMy WebLinkAbout2613 Antelope Rd - Special Inspections/Combustion Safety - 10/27/2017Planning, Development & Transportation
/^ 6 g Ot Community Development & Neighborhood Services
281
h College Avenue
4�1 t otti ns Fort ColliCO 80522.0580
970.416.2740
970 224 6134- fax
fagov com
Combustion Safety Test Compliance Form
Replacement of Natural Draft Appliances in Existing Houses
Home Owners Name: rc So L �"n ^ _ PermitNumber: �170363
Address:) d,6 �_3 A Tele: 6/10,- 949
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: Allen Service License Number: MP-4
Technician Name (print). -t v\ r\ 7
�. _ Date: �C/ a 7 ��
Technician Signature: leer Teele: 567-1 '% G�
Appliance Tested: \,J 'V Model #: e6`, `, fe-o 5 (,5 �' U
Appliance Replaced: Model #:_5-G-
STEP 1: Worst Case Conditions Test L
SpillageBack aft Duration (in seconds): 10 Carbon Monoxide (parts per million):
Pass Fail (Technician neust 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 (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 acknowledge that I have received a combustion appliance safety
information sheet. (initial)
Further information can be obtained at www.fcgov com/buildingigreenclasses.php
New form 3-16-2016