HomeMy WebLinkAbout1338 Vinson St - Special Inspections/Combustion Safety - 03/27/2018Planning, Development & Transportation Services
Community Development & Neighborhood Services
281 North College Avenue
Box 580
'V Fort Fort Collins, CO 80522.0680
970.416.2740
970.224.6134- fax
fcgov.com
Combustion Safety Test Compliance Form
Replacement of Natural Draft Appliances in Existing Houses
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biome Owners Dune:=(„1�1 i ' — / D� Permit Numbe
Address /3 3Jr' -jj -- a°+� ' .F Tele:
Licensed Contractor:d�P��t�t's
I hereby attest that I have performed the following Combustion Safety Test in accord a with Fort
Collins Combustion Safety Test Guide Version 5, February 2012.
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Company Name-f I/ License Number:
Technician Name (print): j&,\1 k v, TrT a t Date: / S
7;echnician Signature: Tele:
appliance Tested:.fq .l ,fl�l ab.lc WA Model #: eQGdS, 1 C1U
. poliance Replaced: Model #:
SI'EP 1: Worst Case Conditions Test
SpilIageBackdraft Duration (in seconds): Carbon Monoxide (parts per million): s
Pass 4 Fail . (Technician must test under Natural Conditions if "Failed")
Technician's recommendations to correct tested appliance failure:
2: Natural Conditions Test
;eBackdraft Duration (in seconds):
Pass Fail
Carbon Monoxide (parts per million):
(Failed test requires corrections until test passes under Natural Conditions.)
3: Home Owner Signature
that I am the legal owner of the above listed property.
s Name (print)
s Signature
Date
the event that my appliance has failed a Combustion Safety Test under worst -case
nditions, I hereby acknowledge that I have received a combustion appliance safety
'ormation sheet. 4 (initial)
Further information can be obtained at www.fcgov.com/building/greenclasses.php