HomeMy WebLinkAbout620 Powderhorn Dr - Special Inspections/Combustion Safety - 12/09/2016Planning, Development & Transportation Services
r Community Development & Neighborhood Sorvices
t ■■■ssss�rrrr�Y OT 281 North College Avenue
�t Collins PO Box 500
r Fart Collins. CO 80522 0560
r 970.416.2740
970 26134• tax j -7,1v
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Combustion Safety Test Compliance Form
Replacement or Natural Draft Appliances in Existing Houses
Home Owners Name: DOUG STOLL permit Number:
Address:620 POWDERHORN DR Tele:
970-491-3708
Licensed Contractor:
I hereby attest that I have perl'ormed the following Combustion Safety Test in accordance with Fort
Collins Combustion Safety Test Guide Version >. February 2012.
Company Name: NORTHERN COLORADO AIR, INC, License Number:
Technician Name (print): ii
Technician Signature:G
Appliance Tested: WATtR HEATER
Appliance Replaced: FURNACE
Model //:
H-837
Date: 12109/2016
Tele: 970-223-8873
Model It: EL195UH09OXE48C
STEP l: Worst Case Conditions Test
Spillage/Backdraft Duration (in seconds): Carbon Monoxide (parts per million):
Pass Fail (Technician must lest carder Natural Conditions if "Failed")
'fechnician's recommendations to correct tested appliance failure:
STEP 2: Natural Conditions Test
Spillage/Backdrati. Duration (in seconds): Carbon Monoxide (parts per million):
Pass Fail
(Failed test requires corrections until test passes under Natural Conditions.)
STEP 3: I lome Owner Signature
I certify that I am the legal owner of the above listed property.
Owner's Name (print)
Owner's Signature
Date 1 � Lo 4
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 information can be obtained at www.tcgov.com/building/greenclasses.php