HomeMy WebLinkAbout1131 Muirfield Way - Special Inspections/Combustion Safety - 01/23/2018Planning, Development & Transportation Services
Clty, of Community Development & Neighborhood Services
281 North College Avenue
F6rt Collins Fort Collins$ CO 80522 0580
gym— 9704162740
970 224 6134- fax
fcgov com
Combustion Safety Test Compliance Form
Replacement of Natural Draft Appliances in Existing Houses
Home Owners Name: `ti'' IC'obev�k -� - Permit Number.
Address- 11-31 m U 1 �r l e cL Tele
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 -�—� License Number
Technician Name (print) 3 '✓6A-,, _C%r&t"ci Date
Technician Signature•
/— Z3 —/Jc�
Tele.
Appliance Tested ff�w AO- Model # lQ�j 0l �/V
Appliance Replaced: Model #
STEP 1: Worst Case Conditions Test
SpillageBackdr Duration (in seconds)- 3 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
SpillageBackdraft 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
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