HomeMy WebLinkAbout4230 Goldeneye Dr - Special Inspections/Combustion Safety - 03/21/2017Fort Collins
Planning, Development & Transportation Services
Community Development 8 Neighborhood Services
281 North College Avenue
P O Box 580
Fort Collins. CO 80522 0580
970.416 2740
970 224.6134- fax
Icgovcom
Combustion Safety Test Compliance Form
Replacement of Natural Draft Appliances in Existing Houses
Home Owners Name: DIRK SOLI_IE Permit Number:
Address:4230 GOLDENEYE DR Tele: 970-223-3965
Licensed Contractor:
I hereby attest that 1 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:
Technician Name (print): MARCUS ORTEGA
Technician Signature: (71- - -
Appliance Tested: WATER HEATER
Appliance Replaced:
FURNACE
H-837
Date: 03/21 /2017
—1 Tele: 970-223-8873
Model #: r� -- - _J
Model #: EL195UH07OXE36B
STEP 1: Worst Case Conditions Test
Spillage/Backdraft Duration (in seconds): Carbon Monoxide (parts per million):
Pass.X Fail (Technician must 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 Condition&)
STEP 3: Home Owner Signature
I certify that 1 am the legal owner of the above listed property.
Owner's Name (print) C- rho L-.t�t
Owner's Signature
Date
In the event that my app ' ion Safety Test under worst -case
conditions, I hereby acknowledge that 1 have received a combustion appliance safety
information sheet. (initial)
Further information can be obtained at www.fcgov.com/building/greenclasses.php