HomeMy WebLinkAbout3903 Ridgeway Ct - Special Inspections/Combustion Safety - 01/20/2017/1/20FEB701_ZOR9�15V1PYSTFROM_ TO:19702246134 FROM:719AF4A4H8544 T-591FIVEli/006 6F-506
y Planning, Development & Transportation Services
'tyOf Community Development a Neighborhood Services
P. North 80118ge Avenue ^
FCOn Q 60
Coltins Fort Collins,
8 ns 00 80522,0580
970.224.6134.lax
fcgov.com I 1 1
Combustion Safety Test Compliance Form
Replacement of Natural Draft Appliances in Existing Houses B I boo zc y
Home Owners Name: 1 Gh Az Permit Number:
Address:_ p Tele: 967p
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: A49f 9&t.- t s 009tTW6-4'41o2 License Number:
Technician Name (print): AwS Date:
Technician Signature: e,,..,.
Tele:
Appliance Tested: - ♦ Model #: 7-
Appliance Replaced: # I I i
Model
STEP 1: Worst Case Conditions Test
SpillageBackdraft Duration (in seconds): Z Carbon Monoxide (parts per million): .S
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): L Carbon Monoxide (parts per million):
Pass Fail
(Failed test requires corrections until test passes under Natural Conditions.)
STEP 3: Rome Owner Signature
I certify that I am the legal owner of the above listed property.
Owner's Name (print) A G46,0j e✓
Owner's Signature _
Date dzidv
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
infonmation sheet. (initial)
Further information can be obtained at www.fcgov.com/building/greenclasses.php