HomeMy WebLinkAbout2814 Canby Way - Special Inspections/Combustion Safety - 08/01/2016a -, 0';'
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;�eGnn:ng, Devaistpment & firanspanation Serielces
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Community Development & Neighborhood Services
281 North College Avenue
P.O. Box 580
Fort Collins, CO 80522.0580
970.416.2740
970.224.6134-fax
Combustion Safety Test Compliance Form
Replacement of Natural Draft Appliances in Existing Houses
Home Owners Name: cul L.E C- Co i C� Ovl C'- Permit Number_
c� Address. E � r ') �`� ` l CC o ,& � Tele: q70-0,37-
Licensed Contractor: �J J
I hereby attest that I have performed the following Combustion Safety Test in accordance with Fort
f Collins Combustion Safety Test Guide Version 5, February 2012.
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Technician Name (print): `I fl &- f Date:
Technician Signature: 4<1 Tele: —,;7 -3
Appliance TesteModel
Appliance Replaced(: Vi od:t 7F
STEP 1: WorstCase Conditions Test
SpillageBackdi-aft Duration (in seconds): $ Carbon Monoxide (parts per million):��m
Pass ✓' Fail (Technician must test under Natural Conditions if "Failed") p` 75t rl
Tccbnicimi s r6co n u ndations w correct ws--wd applance iCdii=
STEP 2: Natural Conditions Test
Spillageack&a Bft Duration (in. seconds)r Carban.Monoxt& (parts per milliml: _
Pass Fail
f
(Failed test `requires corrections until test passes under Natural Conditions.)
STEP 3: Home€ Owner Signature
i c�ati':�a 3>� 1 a� i� It�si a�u�t:r fs;f tires s#s�� dimmed ��-
Owner's Name' (print) `S a.n bra a (�pr aovr
Owner's Signature Date g L
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In the event that my applianc as 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/greenclasses.php