HomeMy WebLinkAbout1306 W Mountain Ave - Special Inspections/Combustion Safety - 01/23/2017112%7111-YOR91 RVUS STFROW TO : 19702246134 FROM: 719�F494Hs5j4 T-599"F 1008 i F-5o5
Planning, Development & Transportation Services
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City of , V �/1 281
Bo°°CO tege ^venue
Fort Collins 97r ;s'274CoaO52�.0580
970.224.e134-fax
kgov.com I �^
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Combustion Safety Test Compliance Form
Replacement of Natural Draft Appliances in lExisting Houses
Home Owners Name: ? get Permit Number: 131106 �� Z
Address: 130� _ W Metu»�'e�;k Ave . Tele: q,74'481-9I5,j
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: h
Technician Name (print):
Technician Signature:
Appliance Tested:
License Number: -13Oct
Date:
Model #:
Tele: V6,M --IS-T
Appliance Replaced: )C v.Ac� Model # _ � ?1y,�/�V J
STEP 1: Worst Case Conditions Test ,r
SpillageBackdraft Duration (in seconds): _q__ Carbon Monoxide (parts per million):
Pass _X_ Fail (Technician trust test under Natural Conditions if "Failed")
Technician's recommendations to correct tested appliance failure:
STEP 2: Natural Conditions Test
Spillage/Backdraft Duration (in seconds): Carbon Monoxide (parts per million):
Pass Fail
(Failed test requires corrections until test passes under Natural Conditions.)
STEP 3: Home Owner Signature
I certify that 1 am the legal owner of the above listed property.
Owner's Name (print) R4 OAC ! d6lf
Owner's Signature I
Date t y®
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/building/greenclasses.ohp