HomeMy WebLinkAbout612 Locust Grove Dr - Special Inspections/Combustion Safety - 12/01/2017Dec 01 1710:02a Hahn plumbing
970-493-5325 p 2
CoUlions
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PlanplFg, Developmeirtz. & Trarmpor°.ation Sesvksa
Community Developanerd & Neighborhood Services
281 North Caege Avenue
P.O. Box 580
Fora Corms. CO 8OW-0530
97a.4t6.2740
470224.5134- fan'
FC90 cam
Combustioit Safety Vest Compliance Form
Replacement of Natural Draft Appliances in E>tfg Houses
Home Owners Name:UrvAck 1 Pemrit Nrmmber QQ
Address: �a � C, 'A �C�V � �� Tele: q10 • R 055
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: License Number. I P-15
TecbnicianName(print): _ e--. I- Date: I 1340 L Z
Technician Signature: Tele:
Appliance Tested: filly - Model g- CrC Ae-- Y v A -o S e-A
Model#:
STEP 1: Worst Case Conditions Test /J
Spillage/Backdraft Duration (in seconds): Carbon Monoxide (parts per million): / Z
Pass / Fail fTeelrnkAm crust test under Natural Cond fions if "Failed')
Technician's recommendations to correct tested appliance failure:
STEP Z: Natural Conditions Test
SpillageBackdra$ Duration (in seconds): Carbon Monoxide (parts per million):
Pass Fail
(Failed test requires carrecffons amW tediumes under Natural Conditions:)
STEP 3: Home Owner Siiguatt re
I ctatify that I am the lqg owner of the above listed property.
Owner's Name (print)
Owns', Signatm
In the event that my appliance has fatted a Combustion Safety Test under worst -case
conditions, I hereby acknowledge that I have received a combustion appliance safety
infornnation sheet. (initial)
Further information can be obtained at urww fcgov com/building/greenclassmphp