HomeMy WebLinkAbout1521 Reeves Dr - Special Inspections/Combustion Safety - 09/04/2018Planning, Development & Transportation Services
City Of Community Development & Neighborhood Services
281 North College Avenue
/Fort Collins Fort Colli s8 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: __R, `c k- Lina o A I Permit Number:
Address: Tele: 'PJG) ,
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: 64J T" sl-� C- License Number: t10 3
Technician Name (print): V'114rv. Date: q </ - %$
Technician Signature: Tele: 3o g - Z76
Appliance Tested: L147- Model #: G 01 72Z �U ^J U4 411a
Appliance Replaced: Model #: 601 1S4yO p_
STEP 1: Worst Case Conditions Te
Spillage/Backdraft Duration (in secon s): arbon Monoxide (parts per milli n): -
Pass x Fail (Technician must test under Natural Conditions if "Fai e .
Technician's recommendations to correct tested appliance failure:
AA
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
certify that 1 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 ackrjKledge that I have received a combustion appliance safety
information sheet. (initial)
Further information can be obtained at www.fcgov.com/building/greenclasses.php