HomeMy WebLinkAbout4763 Prairie Vista Dr - Special Inspections/Combustion Safety - 09/05/2017Planning, Development & Transportation Services
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1---�-F6rt Collins
Community Development & Neighborhood Services
281 North College Avenue
P O Box 580
Fort Collins, CO 80522 0580
970.416.2740
970 224 6134- fax
fcgov corn
Combustion Safety Test Compliance Form J
Replacement of Natural Draft Appliances in Existing Houses
Home Owners Name: ►C`� KA L2� Pen -nit Number: L
Address: 5 (I-IrIka Vtzm Tele:
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: 0. License Number: // iezw,
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Technician Name (print):ot-�Date:
Technician Signature: Tele: ciZU cocaubob
Appliance Tested: Model #: pf
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Appliance Replaced: j� %U �lj� l�cYdel #:
STEP 1: Worst Case Conditions Testf,,yry
Spillage/Backdraft Duration (in seconds):_ Carbon Monoxide (parts per million):
Pass Fail (Technician must test under Natural Conditions if "Failed'q
Technician's recommendations to correct tested appliance failure:
a
I �
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
i 0
'Owner's Name (print) _
In the event that my a
conditions, I hereby
information sheet.
property.
4_ i
Date JIISVii 7—
ii a Combustion Safety Test under worst -case
that Nave received a combustion appliance safety
Further information can be obtained at www.fcgov.com/building/greenclasses.php