HomeMy WebLinkAbout840 Merganser Dr - Special Inspections/Combustion Safety - 03/08/2018Planning, Development & Transportation Services
Community Development & Neighborhood Services
ry% 281 North College Avenue
ff ` ®P.O. Box 580
COA«0 � Fort Collins, CO 80522.0580
970.416.2740
970.224.6134- fax
fcgov"com
Combustion Safety Test Compliance Form
Replacement of Natural Draft Appliances in Existing Houses
Home Owners Name: Qi_�c tnti Permit Number (�0 2L1 S"T
Address: 49-10 M.erGG►,S,/— 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: E/LA,,.r,a r/li'�-r i f , License Number-&P l /
Technician Name (print): CtyrS 1{1.=6u- r e Date: 3 g /,5
Technician Signature: ��� Tele:G/��)-33/Z
Appliance Tested: L(0 gt1le,v 4.7o f/4h. iModel #:
Appliance Replaced: I I It cc < / Model #: P L `i0 N t`r-D
STEP 1: Worst Case Conditions Test
Spillage/Backdraft Duration (in seconds):_ Carbon Monoxide (parts per million): / a
Pass _Fail (Technician must test under Natural Conditions if "Failed")
Technician's recommendations to correct tested appliance failure:
STEP 2: Natural Conditions Test
SpillageBackdraft 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.com/building/greenclasses.php