HomeMy WebLinkAbout3220 Grand Teton Pl - Special Inspections/Combustion Safety - 04/10/2018I/2APf _2018 0%:JRMAMF&O T TO:19702246134 FROJ1 d4jaAJ07234 T-155 P.o01/Ve:F-9111
Planning, Development & Transportation Services
CityCommunity Development & Neighborhood Services
Y 281 North College Avenue
Fl Oort Collins P.OseX68D
Fort 6.2, CO 80522.0580
97D.418.2740
970.224.8134-fax
ft:gov.com
Combustion Safety Test Compliance Form
Replacement of Natural Draft Appliances in Existing Houses
Home Owners Name::41h11PPermmittNumber:Address:�Lkm p L l �Acl �� (7J: 1�le:
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: Fort Collins Heating,and Air licenseNumber: H1309
Technician Name (print): Date.
Technician Signature: Tele:
Appliance Tested: Model #:
Appliance Replaced: / Model #:
STEP 1: Worst Case Conditions Test
SpillageBackdraft Duration (in seconds): Carbon Monoxide (parts per million): _
Pass Fail X (Technician must test under Natural Conditions if "Failed")
Technician's recommendations to correct tested appliance failure:
STEEP 2: Natural Conditions Test
Spillag ekdraft Duration (in seconds): L Carbon Monoxide (parts per million): L
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.
-e Owner's Name (print)
Ir Owner's Signature
In the event that my
conditions, I beret
information sheet. c
lie Kos ,P—
Date 4+ - I O - D 01 Q
has failed a Combustion Safety Test under worst -case
edge that I have received a combustion appliance safety
Further information can be obtained at www.fogov.com/building/greenclasses.php
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