HomeMy WebLinkAbout1124 Pheasant Dr - Special Inspections/Combustion Safety - 07/29/2016From:
01/16/2017 10:43 #464 P.002/002
City Of
®rt Collins
Planning, Development & Transportation Services
Community Development & Neighborhood Services
281 North College Avenue
P.O. Box 580
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: ;tea, f Permit Number:—z\laity SS
Address:. \\ ,\k j Tele:
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 Natne t1�`AA , License Number: ll� -�3S
Technician Name (print): ` ,A, ate:% —
Technician Signature: Tele:
Appliance Tested: Model #—�G Z\Ao-Uo'U - ► DS
Appliance Replaced: \-NN Model #:
STEP 1: Worst Case Conditions Test
Spillage/Backdraft Duration (in seconds): 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
SpillageBackdraft Duration (in seconds): 0 Carbon Monoxide (parts per million): 45
Pass A— 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)
Owner's Signature
Date
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.fegov.com/buildingloeenclasses.php