HomeMy WebLinkAbout3415 Golden Currant Blvd - Special Inspections/Combustion Safety - 02/15/2018Planning, Development & Transportation Services
cl t �� Community Development & Neighborhood Services
F6rt
y 281 North College Avenue
Collins Fort Co Collins, CO 80522.0580
970.416.2740
970,224.6134- fax
rcgov.com
Combustion Safety Test' Compliance Form
Replacement of Natural Draft Appliances in,Existing Houses Q�
Home Owners Name:. DAMES MCDONALD Permit NumberC
,GOLDEN-CURRANT-BLVD1 970-215-8998
Address: ' -'� ; b 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: NORTHERN COLORADO AIR, INC.
Technician Name (print): MARCUS ORTEGA
License Number: H-837
Date: 02/15/2018
Technician Signature: Tele: 970-223-8873
Appliance Tested: WATER HEATER Model #:
Appliance Replaced: FURNACE Model #: SLP98UH110XV60C
STEP 1: Worst Case Conditions Test d
Spillage/Backdraft Duration (in seconds): Carbon Monoxide (parts per million): _
Passj 1 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 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 (printAlit Q c ()a ^a ti/1
Owner's Signature Date /'� S Flo, Zo 1
In the event that my appliance has failed a Combustion Safety Test under worst -case
conditions, I hereby acknowledge that l have received a combustion appliance safety
information sheet. _r (initial)
- Further information can be obtained at www.fcgbv.com/building/greenclasses.php