HomeMy WebLinkAbout1819 Manchester Dr - Special Inspections/Combustion Safety - 03/16/2018Planning, Development & Transportation Services
Community Development & Neighborhood Services
City O�
Ci C C 281 North College Avenue
FV rt Collins Box 50
Fortrt Colli s8 CO 80522.0580
970.416.2740
970.224.6134- fax
.4 fcgov.com
Combustion Safety Test Compliance Form
Replacement of Natural Draft Appliances in Existing Houses
Home Owners Name: kkr,64Jot>� Permit Number: 9,3 \ beak
Address: mck � �p c Z)t' Tele: �AgS-15SR
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: tA-$3S
Technician Name (print): r' Date: a\1a\A
Technician Signature: JAITele: Crh-qt�2-aoSO
Appliance Tested: n� �Q1 ��(�,P.G-� Model#: ®RO�jAT6N-
Appliance Replaced: S� i7 i,JA p(�-}p�_ Model #:
STEP 1: Worst Case Conditions Test
SpillageBackdraft Duration (in seconds): j_ Carbon Monoxide (parts per million): 12
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 (in seconds): _ Carbon Monoxide (parts per million):
Pass Fail
(Failed test requires corrections until test passes under Natural Conditions.)
STEP 3: Home Owner Signature
1 certify that I am the legal owner of the above listed property.
Owner's Name (orint:k 1herrtA E% Wca-Zr1
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/building/greenclasses.php