HomeMy WebLinkAbout2628 Leisure Dr - Special Inspections/Combustion Safety - 04/26/2016Development & Transportation Services
Clt of K(;bmmunityDevelopment 8.Neighborhood Services
`� ?�81 North College Avenue
Fort COR I ns _ P.O. Box 680
Fort Collins, CO 80522.0580
970.416.2740
970.224.6134- fax
fcgov.com
Combustion Safety Test Compliance Form
Replacement of Natural Draft Appliances in Existing Houses
Home Owners Name: llc le-Lt-e-6ti- Permit Number:
Address: n Tele: q7 o
Licensed Con ra tc o� S `� ` `
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: 4J(." S-G. ✓ , C-e.., License Number: wt P- Y
Technician Name (print): 8a/w::�. "k' Date: VZ�
Technician Signature: ��c�-� Tele:
Appliance Tested:
Model #: ( (a l U_j 0o-y ( 'L
Appliance Replaced: wk-t, 4-p— ` Model
STEP 1: Worst Case Conditions Test SpillageBackdraft Duration (in seconds): /00 Carbon Monoxide (parts per million): / yv
Pass Fail (Technician must test under Natural Conditions if "Failed')
Technician's recommendations to correct tested appliance failure:
STEP 2: Natural Conditions Test / ,
SpillageBackdraft Duration (in seconds): 1� Carbon Monoxide (parts per million): Q �
Pass T Fail f/ (/
(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.fegov.com/building/greenclasses.php
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