HomeMy WebLinkAbout2514 Owens Ave - Special Inspections/Combustion Safety - 05/15/2018Planning, Development & Transportation Services
eoff m my Devetop nwrt & NeWdwrhood S;ervicm
City of zst North Caege Avenue
Fort Collins FO00-0
97GA16.2740
970.224.6134-fax
Combustion Safety Test Compliance Form
Replacement of Natural Draft Appliances in Existing Houses
Home Owners Name: c h a r o! COn e % Pemut Ntm>ber: ! SO 6 y
Address: aP O ow CrS vC'/ A I G / Tele:
Licensed Contracror.
I hereby attest that I have performed the following Combustion Safety Test in a<xardance with Fart
Collins Combustion Safety Test ()dde Version 5, February 2012.
Company Name: �.^ [. 1 iI h License Number: YZ
Technician Name (print):. /l o-S e✓i f , Date:
Technician Signature: /,f+��—, Tele:
Appliance Tested: t. 046'✓ 6 Pr~ + P✓ Model*
Appliance Replaced:
Model
STEP 1: worst Case conditions Test Spill apAlackdraft Duration (in seconds): L_Ll ���0 0 Carbon Monoxide (parts per million):
Pass _ Fail (Te cArnicimt surd test undue Natural Conditions if "Faffed')
Technician's recommendations to correct tested appliance faihire.
STEP 2: Natural Conditions Test
SpillagetBackdraft Duration (in seconds): Carbon Monoxide (pacts per million):
Pass Fail
(Fa" test mquaw comedi'ons unaT test passes under Natural Conditions)
STEP 3: Home Owner Signature
I certify that I am the legal owner of the above listed property.
Owner's Name (prim)
Ownces 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 infomoation can be obtained at www fcgov.convbuildmgtgreenclasses pbp