HomeMy WebLinkAbout1525 Preston Trl - Special Inspections/Combustion Safety - 01/11/2017Development & Transportation Services
. nunity'bovelopment &.Neighborhood Services
NoGh College Avenue.
'.� "ax 580
'tort CoMps, CO 80522.0580
970.416.2740'
5 %0 22 .,g134- Fax
fagov.com
Combustion Safety Test Compliance.Form
Replacement of Natural Draft Appliances in Existing Houses
Horne Owners Namel Permit Numter-,46/7��/t
Address: Tele:
Licensed Contractor:
I hereby attest that I have performed the following Combustion SaQk Test in accordance with Fort
Collins Combustion Safety Test Guide Version 5, February 2012.
Company Name: Allen Service ' J License Number: MP-4
Technician Name (print): _t (�,�t S �/ flit r� IL-6 Date: I ��
Technician Signature:���/1
Appliance Tested: Model#:
Appliance Replaced:�jC� Model
STEP 1: Worst Case Conditions Test a
SpillageBackdraft Duration (in seconds): 2C. Carrbon"Monpxide (parts per million):
Pass Fail (Technician:, must-.tes;,under-Mural Conditions if "Failed')
Technician's recommendations to correct tested app 'ance failure:
STEP 2: Natural Conditions Test
SpillageBackdraft Duration (in seconds): Carbon Monoxide (parts per million):
Pass Fail t"
(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.fcgov.com/building/greenclasses.php
New form 3-16-2016