HomeMy WebLinkAbout1400 Shamrock St - Special Inspections/Combustion Safety - 02/14/2018eRt ('2-_ i E°'$c nspoftdon Be, -vices
COM munftY 0e12lop rient 1= Neighborhood SerAces
281 Moth College Avernze
P.O. Sax 58o
t-wt Collihs, CO 8052 O580
y70.418.274G
s70.224.6i34-iax
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Combustion Safety Test Compliance Form
Replacement of Natural Draft Appliances in Existing Houses
H-0 ewners Name: ✓ I `�'� .,„ , x, Permit Number �_� Z-�%
Address
t icensed 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:
License
Technician Name (print): li v Date: �t
r� Technician Signature: ,�'`Jz4 L Tehe:
Appliance Tested. H c:1 r r, .1 Model *_ �44 14 0y
Appliance Replaced: H e ,N 4 e i, Model #: r
STEP 1: Worst Case Conditions Test
SpihlagelBac aft Duration (in seconds): Carbon Monoxide (parts per million):
Pass Fail (Technician mast test under Natural C'ond moons if aFaalcd "j
Technician's recommendations to correct 4"n;lr►rw
STEP 2: )Natural Conditions 'best
Spillage/Backdraft Duration (in seconds): Carbon Monoxide (parts per million):
Pass Fail
(Fulled test requires corrections antd test passes under Natural Condition&)
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 r-
Date -IL'
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/buikling/greenclasses.php