HomeMy WebLinkAbout3220 Mesa Verde St - Special Inspections/Combustion Safety - 03/31/2017City of 0
Fort Colhns,,(".41
Planning, Development & Transportation Services
Community Development a Neighborhood Services
281 North College Avenue
P.O. Sox 580
Fort Colllns, CO 80522.0680
970.416.2740
970.224.8134-tax
tagov. com
Combustion Safety Test Compliance Form
Replacement of Natural Draft Appliances in Existing Houses
Home Owners Name: OH ki I11�r Permit Number: Q I LPO 5
Address: 3ZZ-0 CL Vef V . Tele:
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: Fort Collins Heating and Air License Number:
Technician Name (print): —c�fb� P Date:
Technician Signature:
Appliance Tested: OV�D Model #:
Appliance Replaced:
Model k:
H 1309
3
Tele:
STEP 1: Worst Case Conditions Test
Spillage/Backdraft Duration (in seconds): 3 Carbon Monoxide (parts per million): Jl✓
Pass %L Fail (Technician must test under Natural Conditions if "Failed'q
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 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, 1 hereby acknowledge that 1 have received a combustion appliance safety
information sheet. (initial)
Further information can be obtained at www.fcgov.com/building/greenclasses.php