HomeMy WebLinkAbout3338 Golden Currant Blvd - Special Inspections/Combustion Safety - 01/16/2018Development & Transportation Services
ommunity Development & Neighborhood Services
281 North College Avenue
P.O. Box 580
Fort Collins, CO B0522.0580
970.416.2740
970.224.6134-fax
rcgov.com
Combustion Safety Test Compliance Form
Replacement of Natural Draft Appliances in Existing Houses
� lrol� 1
Home Owners Name: jPermit Number: �e31
Address: J���/�/'l.��� ' 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: Allen Service
Technician Name (print):
Technicians Signature:
Appliance Tested: tb &
Appliance Replaced:
License Number: MP-4
rDate:
i
fir `i
STEP 1,- Worst Case Conditions Test
SpillageBackdrraaft Duration (in seconds): Carbon Monoxide (parts per million):
Pass J/ Fail {'Technician must 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 testpasses 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 Signatuure
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
WaIt
Supply Valve �,, • -.._ If your waf er hp�* --aking or breaks d¢ r=