HomeMy WebLinkAbout729 Smith St - Special Inspections/Combustion Safety - 11/28/2017Nov 29 17 01.23p Hahn plumbing
970-493-5325 p 2
i
. of
Plannft, Devaiopment & Tranapartation Servk*s
Community Development & AWghbottmcd Services
281 Noah CoUge Avenue
P.O. Box 580
Fort CoMm. CO 80522.0580
870AM2740
S70.224.6134-tat
rogov. com
Combustion Safety Test Compliance Form
Replacement of Natural Draft Appliances in Existing Houses
Home Owners Name: �1t2 a VIfj5nnQLnPermit Number.
Address: '"I L - 5bl , Tele: ono �droi' 3a� 3
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 2D12.
Company Name:
Technician Name (prim):
Technician Signature: /
Appliance Tested: W i
Appliance Replaced: �
License Number. MP—l5
A' -tee- 1
Tele:
Model #:A'062'le-5-6,?1
Model#
STEP l: Worst Case Conditions Test
SpillageBarkdraft Duration (in seconds): 0 Carbon Monoxide (parts per million):
Pass Fail (Technician must rest under Natural Conditions if "Failed "j
Techni -s recommendations to correct tested appliance failure:
STEP 2: Natural Conditions Test
SpUlage(Backdunfr Duration (in seconds): Carbon Monoxide (parts per mri$on):
Pass Fail
(Failed test requires coneclions untr7 test passes under Natural Coni idom )
STEP 3: Home Owner Signature
I ceatify that I am the dal owner of the above listed propefty.
Owner's Name (print)
Owner's Signatre
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.comlbuilding/greenciasses.php