HomeMy WebLinkAbout812 Garfield St - Special Inspections/Combustion Safety - 09/28/2017Fort Collins
Planning, Development & Transportation Services
Community Development a Neighborhood Sorvices
281 North College Avenue
P.o Box 580
Fort Collins CO 80522 0580
970.416.2740
970 224 6134•tax
kgov,com
Combustion Safety Test Compliance Form ( �� t7 —�
Replacement of Natural Draft Appliances in Existing Houses
Home Owners Name: JEAN SUTHERLAND Permit Number: e? F—W �?
Address:812 GARFIELD ST Tele:
970-493-0157
Licensed Contractor:
I hereby attest that l have performed the following Combustion Safety Test in accordance with Fort
Collins Combustion Safety Test Guide Version 5, February 2012.
Company Name: NORTHERN COLORADO AIR, INC. License Number: H-837
Technician Name (print): SCOTT ZIEGLER
Technician Signature:
It
Appliance Tested: W4
Date: 09/28/2017
Tele: 970-223-8873
Model #: AG Z540 I
Appliance Replaced: WATER HEATER Model #: RG240T6N
STEP 1: Worst ase Conditions Test
Spillage/Back ft Duration (in seconds): Carbon Monoxide (parts per million):
Pass Fail (Technician ust test under Natural Conditions if "Failed'
Technician's recommendations to correct tested appliance failure:
STEP 2: Natural Conditions Test
Spillage/Backdraft 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/building/greenclasses.php