HomeMy WebLinkAbout1234 Maple St - Special Inspections/Combustion Safety - 12/18/20170KI
' Plannhig,-Derrelop ment 9 Ti-ansportatlon See€view
Community Development S, Blelghborhood Services
281 North College Avenue
P.O. Box 560
Fart Collins. Co 80MZ0580
970A162740
970.224.6134--tax
Combustion Safety Test Compliance ]Form
Replacement of Natural Draft Appliances in Existing Houses
Home Owners Name: K-e'D l Q le m-ey Permit Number """"'
Address:_ 62'5y - /t9q IQf k r ca�1l,�,o Tele: 910 • Q226SM9
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: &M R Ll'(CI,pI MLWULaQ License Number: MP-15
Technician Name (print): Date:_)
Technician Signature: _� L t ! Tele:c cZ
Appliance Tested v> Model #: r
Appliance Replaced: w Model k
STEP 1: Worst Case Conditions Test
SpillageMackdratt Duration (in seconds): Carbon Monoxide (parts per million):.Z
Pass �4_ Fail (Technician must test under Natrtral Conditions if "Failed'°)
Technician's recommendations to correct tested appliance failure:
STEP 2: Natural Conditions Test
SpillageBackdra8 Damon (in seconds): Carbon Monoxide (parts per million):
Pass Fail r
(Failed test requires corrections un l tesi passes under Natural CondXona)
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 _
In the event that MY applies has failed a Combustion Safety Test under worso case
conditions, I hereby acknowledge tbat I have received a combustion appliance safety
information sheet, (initial)
Further information can be obtained at www-fcpv.com/baikfing/greenciasses.php