HomeMy WebLinkAbout4900 Boardwalk Dr - Special Inspections/Combustion Safety - 03/03/2018s?Ft'i c'-. TMIPS porca, 10
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Community Cetre[opnaent c Neighborhood Se. (ices
c 281 moth College Avenue
P.O. Box 580
'•�_ u 5 " 'V'f ! 3C Fon Collins, CO 805nQ580
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Y\ '" £70.06.274C
270 224.613&iax
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Combustion Safety Test Compliance Form
Replacement of Natural Draft Appliances in Existing Houses
Home Owners Name: (S Permit Number 5I ed> I -jq 5
Address:\q C<l0 \\\ C,f n\ C. V. \ K — ..1 �% .-n T-I-.
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: bn� ambj na l CIS License Number:4 lQ- Jr
Technician Name (print): \_ �r X Date:
Technician Signature:L2 ,,E ,� �Z Tele:
Appliance Tested: W cNe ; \fix• . Model #
Appliance Replaced: k \"Sk3AQz Model
STEP 1: Worst Case Conditions Test
SpillageMackdraft Duration (in seconds): J _ Carbon Monoxide (parts per million): \ i-
Pass f Fail (TechnicianMust test tinder Nateeral Conditions if "Fariledn)
Technician's recommendations to correct tested appliance failure:
STET' 2: Natural Conditions Test
SpillageBackdraft Duration (in seconds): Carbon Monoxide (parts per million):
Pass Fail
(Failed test requires corrections until test passes under Naturral Condwons.)
STEP 3: Rome 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.fegov.com/building/greenclasses.php