HomeMy WebLinkAbout1816 Remington St - Special Inspections/Combustion Safety - 02/07/2018CI �C:vllins
Planning, Development & Transportation Services
Community Development S Neighborhood Servicas
281 North College Avenue
P O. Box 580
Fon Cabs, Cd 80522,0580
970.416.2740
970.224.8134- faX
k9ov'Com
Combustion Safety Test Compliance Form
Replacement of Natural Draft Appliances in Existing Houses C�/2
Home Owners Name: A,,- (� ,S'a,+ me-rS Permit Number: � t0
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Tele• 9i'7 ;;Z.27- Q y!
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:' S License Number: /
Technician Name (print): / r� rc�,�s, Date: 7 7
Technician Signature: �• r� ;,,� . Tele•
Appliance Tested: ,���;ard 44'. r 4mk,W%a,]'ri Model #: X6ASo 7'IA1
Appliance Replaced:
Model #:
STEP 1: Worst Case Conditions Test
Spillage/Backdraft Duration (in seconds): Carbon Monoxide (parts per million): .91
Pass N.. Fail (Technician must test under Natural Conditions # "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 (print) Irl a L r/
Owner's Signature `� "'� " Date
7-/ "7 j l V
In the event that my appliance has failed a Combustion Safety Test under worst -ease
conditions, Z hereby acknaiwledge that I have received a combustion .appliance safety
information sheet. 14 G`'`�(initial)
Further information can be obtained at www.fegov.com/building/greenclasses.php