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HomeMy WebLinkAbout3647 Copper Spring Dr - Special Inspections/Combustion Safety - 12/19/2016Planning, Development & Transportation Services 4.�� �t, of Community Development & Neighborhood Services _ 281 North College Avenue Collins P.O. Box 580 Fort Collins. CO 80522.05B0 50 !ay„� 970.416.2740 970.224.6134- fax fcgov.com Combustion Safety Test Compliance Form Replacement of Natural Draft Draft Appliances in Existing Houses Home Owners Name: &-)dl0 f O &hO 511 Permit Number: Address:% 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: rorI;IA� License Number: Technician Name (print): (_ "rawl.f— Date: Technician Signature: IM ' Tele: Appliance Tested: Model #: Appliance Replaced: &XyLa. ut, Model #: V,67NIi RQS(wt7& STEP 1: Worst Case Conditions Test SpillageBackdraft Duration (in seconds): ♦5W Carbon Monoxide (parts per million): 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): 5Sce.. Carbon Monoxide (parts per million): Pass X_ Fait (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) 5 U 1 PTO �i i I© ,S i f _.. —Owner s Signatuie c�:,T%o Date 1 Z A9 fe 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. SG (initial) Further information can be obtained at w\vw.fcgov.com/buildingigreenclasses.php