HomeMy WebLinkAbout1104 Stover St - Special Inspections/Combustion Safety - 02/01/2018.W
Planning, Development
& Transportation Services
Community Development & Neighborhood Services
City Of
ort Collins P 0 Bo h College
x 580
F Bo
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: �r^ t c, Eco vdz- Permit Number: (� I S [ j
Address: c I,-� a 5►�So� e:� Tele:?G, — %�.g3
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: A -ret& r✓ yt- A License Number: H-200 6
Technician Name (print): Gin/ 1 Date: d:b fig
Technician Stgnatur Tele: % —yaZ 0
Appliance Tested: Po't' le r Model #:
Appliance Replaced: go i( e- r Model #: / ?o?, j 7/ O 6 S` 9 O�
STEP 1: Worst Case Conditions Test
Spillage/Ba kdraft Duration (in seconds): Carbon Monoxide (parts per million).
I
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 (iri 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, I hereby acknowledge that I have received a combustion appliance safety
information sheet. (initial)
Further information can be obtained at www.fcgov.com/builcbng/greenclasses.php