HomeMy WebLinkAbout820 Merganser Dr - Special Inspections/Combustion Safety - 11/30/2018Plan Carta, Developme€tt a tar-portation
Commsmity t VdOPmed & Ndghborhood services
2Bt NGMCOUegeAvenue
CORMIns Post Coffm. Co BOMOSao
9M4t6M40
970.224.61-R& fax
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Combustion Safety Test Compliance Fonn _
RepiaceramtofNatutrA Draft Appliances in InstftHouses
Home Owners Name:
PetnmitN,mber- B 0993
Licensed Contractor.
I hereby attest that Ihave performedAe. followingrambustion Sa&WTest io actsffdame with For
Collins Combusdon Safety Test Cnnde Version 5, February2012.
CompanyName� �BI/(J// p '�• lyiceeNumber
Technician Name (print). 7 Z-C,
Technician Signature TeIe:3
Appliance Tested 0 " 411 24 S tM4 Model. Z%0 —4106
Appliance Replaced: ,t it / i / c Model k (P a L - YJ %YO— 34)
STU l: Worst Case Conditions Test
Spillag Ba&draft Duration (M seconds): Carbon Monoxide (parts per mtlliion):
Pass ,,r Fait (Teehme an mug terse URdWNaWFd ConMnns if "Fafte)
Terltmcian's recommendations to conecttested appliance failure:
STEP 2: Natural Conditions Test
SpllageBacWrdft Duration (in seconds). Carbon Monoxide (parts per mffIion)
Pass Fad
(Fatted t&W wq&*w coprectsons until tatpasses 'Natural ConMom)
STEP 3: Home Owner Signature
I c m ifythatI am the legal owner ofthe above listedpmperty.
Owner's Name (print)
Owner's Signature
Date
In the event that my appliance has failed a Combustion Safety Test under wow -case
conditions, I hereby aclinowledgethat I have received a combustion appliance safety
information sheet.. • (mitial)
Furtherinformation can be obtained at www.fcgov com/bud mgfgmmelmses pbp