HomeMy WebLinkAbout1226 W Prospect Rd - Special Inspections/Combustion Safety - 12/08/2017Dec 08 17 01:35p Hahn plumbing
970-493-5325 p.2
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?lar'plIng, E- ra€tspoeta'don Set -vices
Community Devrelopme tt & Neighborhood Services
281 Ncdh College Avenue
P.O. Box 580
Fort Collins, CO 80522D560
970,41e.2740,
970.224.6134-1=
fccov com
Combustion Safety Test Compliance Form
Replacement of Natural Draft Appliances in Existing Houses
Home Owners Name: �n U 1,,\ Mf.'I �" ermit Number.
Address: i "(0 W • l . as pje d ?,A Tele: Cm
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: jaIIIj
Technician Name (print):
Technician Signature:l
Appliance Tested:
Appliance Replaced: W
License Number:
Date: Z
Model
Model
.+
STEP 1: Worst Case Conditions Test
SpffiageBa aft Duration (in seconds): YV Carbon Monoxide (parts per million):
Pass 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 cm7ecdoms nnta test passes under Natural Condition&)
STEP 3: Horne 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.ftov.com/building/greeucWses.php