HomeMy WebLinkAbout505 S Taft Hill Rd - Special Inspections/Combustion Safety - 02/09/2017Feb 10 1712:55p Hahn plumbing 970-493-5325 p.1
d4
9A4 ,
Planning., D-eveloprnent & Transportation Bernice=
Community Development & Neighborhood ServrC89
281 North Cdlege Avenue
P.O. Box 580
Fort Collins, CO 80522.03e0
970.416.2740
970.224.6134-tax
fcgovxom
Combustion Safety Test Compliance Form
Replacement of Natural Draft Appliances in Existing Houses
Home Owners Name: CGa d d2'rz k F t A Permit Number:, I-1OO 5 3 I
Address: Ti5 TaC-1, (fr l l RD Tele: Qt S - 6 f5?)-7
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:y`DIt1QA- 11(wkLicenseNumber: M?-IS
Technician Name (print): Date: Z-?-17
Technician Signature: Tele:
Appliance Tested Model #: 6v /OU - `/00A - /
Appliance Replaced: k11LI Model #:
STEP 1: Worst Case Conditions Test
Spillage/Backdraft Duration (in seconds): 4�� Carbon Monoxide (parts per million). 1-5—
Pass Fail' (Technician must test under Natural Canditions if "Failed')
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: 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, Thereby acknowledge that I have received a combustion appliance safety
information sheet. (initial)
Further information can be obtained at www.fegov.comlbuildinglgreenclasses.php