HomeMy WebLinkAbout4131 Dillon Way - Special Inspections/Combustion Safety - 11/21/2018Planning, Development & Transportation Services
City. O f Community Development 8 Neighborhood Services
281 North College Avenue
ForCollins F.o.Box560
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: TRAVIS SMITH
Permit Number: P::� I FOM /
Address:4131 DILLON WAY Tele: 303-819-8636
Licensed Contractor:
I hereby attest that 1 have performed the following Combustion Safety Test in accordance with Fort
Collins Combustion Safety Test Guide Version 5, February 2012.
Company Name: NORTHERN COLORADO AIR, INC. License Number: H-837
Technician Name (print): MARCUS ORTEGA
Technician Signature:
Appliance Tested: WATER HEATER Model
Appliance Replaced: FURNACE
Date: 11 /21 /2018
Tele: 970-223-8873
Model #: EL196UH07OXE36B
STEP 1: Worst Case Conditions Test
Spillage/Backdraft Duration (in seconds): _ Carbon Monoxide (parts per million): /.0
Pass _ i Fail (Tecirmcian 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
I certify that I am the legal owner of the above listed property.
Owner's Name (print) �N, Tyue. ,E.5 (�r,�
Owner's Signature
Date -I 1 2 } Za r
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. t&� (initial)
Further information can be obtained at www.fcgov.com/building/greenclasses.php