HomeMy WebLinkAbout4727 Dusty Sage Loop - Special Inspections/Combustion Safety - 01/10/2018Planning, Development & Transportation Services
City
Community Development & Neighborhood Services
281 North College Avenue
Flirtff
QC i n P O Box 560
Fort Collins, CO 80522 0580
970 416 2740
�. 970 224 6134- fax
fcgov com
Combustion Safety Test Compliance Form
Replacement of Natural Draft Appliances in Existing Houses
Home Owners Name: W F,1.1,7 .41 PsE i G.y Po L. Permit Number
Address F4 7 ;I j- Ov.sr,, 5+4 z J—e x _ W� Y —% Tele:g4u - 2z3 - cil
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: pA?2it:k License Number
Technician Name (print)- S/Kq.w� A rt c t `Q Date I / / 042 o i �
Technician Signature �G---c Tele y�o-�9S-Y1fiZ
Appliance Tested: Ev+rg-a- Nt of rr1Z- Model #: i9W - 4sv - 3S{.y�k60N
Appliance Replaced. w+rL'¢. HGA• Lgy- Model #-
STEP 1: Worst Case Conditions Test
SpillageBackdra,Duration (in seconds)- ; sr,e-- Carbon Monoxide (parts per million) -
Pass 4- Fail (Technician must test under Natural Conditions if "Failed')
Technician's recommendations to correct tested appliance failure,
STEP 2: Natural Conditions Test
SpillageBac'kdraft Duration (in seconds). Carbon Monoxide (parts per million):
Pass (/raFail
(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
Owner's Name (pnJ 1 '-4-& h
Owner's
listed property
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/buildmg/greenclasses php