HomeMy WebLinkAbout2720 Rock Creek Dr - Special Inspections/Combustion Safety - 03/19/2018Planning, Development & Transportation Services
f^i� of Community Development& Neighborhood Services
�r y 281 Noah College Avenue
t W n P.O. Box 580
Fort Collins, CO 80522.0680
970.416.2740
970.224.6134-fax
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Combustion Safety Test Compliance Form
Replacem
ent of Natural Draft Appliances in Existing Houses
Home Owners Name: PenuitNtmiber: ,P\ CMIlfoq
Address: 9-7a•-0 �Od k- 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 License Number: MP-4
Technician Name (print):,& �- Q t 1%1% t o { }— Date:
Technician Signature: 2,d2Y� Tele:
Appliance Tested: qO i, L(#>n tJ 1'' Model #: � � D BRT l%
Appliance Replaced: I < , C(o, (�L) Model b Q D 6&7
STEP 1: Worst Case Conditions Test
SpillageBackdraft Duration (in seconds): t Carbon Monoxide (parts per million): LD
Pass Fail (Technician roust 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 (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.comfbuilding/gz•eenclasses.php
New form 3-16-2016