HomeMy WebLinkAbout2718 Pampas Dr - Special Inspections/Combustion Safety - 09/28/2018Combustion Safety Test Compliance Form
Replacement of Natural Draft Appliances in Existing Houses
Home Owners Name: ISA�v G2uO,;A�-�_ Permit Number. Q $ O $15E`F1
Address: 'Z 7 /. R P11-M?t9S- Tele: 97� ZI 19 3)
Licensed Contractor:
1 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: Fort Collins Heating and Air License Number:
Technician Name (print): Sy;3 6 V_ AJ91 Date:
Technician Signature: 4,1 y
H 1309
!2- 2fC-/,F
Tele: 970999 f-5/S�'Z.
Appliance Tested: t3ala 0/ - D '�/+` rr Model #: R d" Z �TG/v
Appliance Replaced:
Model #:
STEP 1: Worst Case Conditions Test
SpillageBackdraft Duration (in seconds): �_ Carbon Monoxide (parts per million): _L
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 corrections until test passes under Natural Conditions.)
STEP 3: Home Owner Signature
1 certify that 1 am the legal owner of the above listed property.
Owner's Name (print) ��os C-ti'uoKa1 t_
Owner's Signature ,y� C.L<kl 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. �L (initial)
Further information can be obtained atwww.fcgov.com/building/greenclasses.php