HomeMy WebLinkAbout2800 Ringneck Dr - Special Inspections/Combustion Safety - 01/26/2017KY oar a
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Planning, Development & Transportation Services
Community Development & Neighborhood aervleas
281 North Goleta Avenue
P.O. Box 880
Fort Colin, CO 80622.0880 aN
870A16.27"
97 W.Co6134 fax
logov.ca
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Combustion Safety Test Compliance Form
Replacement of Natural Draft Appliances in Existing Houses UWL
e Owners Name:
Permit Number - -
Hon
Address:
- Tale:
— — — -- -
Licensed Contractor: with
I hereby attest that I have performed the following Combustion Safety Testaccordance
2 ��� Fort
Collins Combustion Safety Test Guide Version 5, Febmary 201
Company Name:
7� License Number:
Technician Name (print): $ Date: p
Technician Signatufe:
✓ Tele• D YZFL /
Appliance Tested: f� Model #:
Appliance Replaced: Model #:
STEP 1: Worst Case Conditions Test
Spillage/$ae 8 Duration (in seconds): Carbon Monoxide (parts per million):
Pass Fail (Technician "rust test under Natural CondWons if "Fatted")
Technician's recommendations to correct tested appliance failure:
STEP 2: Natural Conditions Test
SpillageBackdraft Duration (in seconds): Carbon Monoxide (parts per million):
Pass . Fail
(Failed test requires corrections until test passes under Natural Conditions.)
STEP 3: biome 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.fcgov.cOm/building/greetclasses'PhP