HomeMy WebLinkAbout807 Arbor Ave - Special Inspections/Combustion Safety - 03/23/2018i
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• • Planning, Development & Transportation Services
Community Gevetopm@nt & NeighbodMae Services
281 Nodh Oollege Avenue
P.O. Box 580
Fon Collins, Co 80522.0680
970A16.2740
870.224,6134- fax
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Combustion Safety Test Compliance Form -
Replacement of Natural Draft Appliances in E3isting Houses
kome Owners Name: „Permit Number:
Address: _ Tele:..976- 7q '
Licensed Contractor: * 6oGrzCe- ho ✓�+wn jurt e+ �
1 hereby attest that I have performed the following Combustion Safety Test in accordance with Fort
' ! Collins Combustion Safety Test Guide Version 5, February 2012. K
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Iompany Name: License Number:
Technician Name (print): Date:
Technician Signature: 'Fete•
Appliance Tested: SOd,, i rv: "k . Model #; A GoZSO TA
.,t 0liance Replaced: Model #:
$I'EP 1: Worst Case Conditions Test
pillage/Backdratt Duration (in seconds): S Carbon Monoxide (parts per million): 3-7-
Pass Fail (Technician must test under Natural Conditions if "Failed")
TOhnician's recommendations to correct tested appliance failure:
STEP I Natural Conditions Test
Spillage/Backdrati Duration (in seconds): Carbon Monoxide (parts per million):
i Pass Fail
(F'ailed,test requires corrections until test passes under Natural Condj&ns.)
S'FP 3: Home Owner Signature
1'4dfy that I am the legal owner of the above listed property,
Owner's Name (print)
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4�er's Signature Date
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In; he event that my appliance has failed a Combustion Safety Test wider worst -case
eoi>ditions, Thereby acknowledge that Y have received a combustion appliance safety
ini,tmation sheet. (initial)
Further information can be obtained at www.fcgov.com/buildin g/greenclwses.php