HomeMy WebLinkAbout2727 Amber Waves Ln - Special Inspections/Combustion Safety - 04/05/2018Planning, Development & Transportation Services
Cit y �f Community Development & Neighborhood Services
281 North College Avenue
P.O. Box 580
Fort Coltins Fort Collins, CO 80522.0580
970.416.2740
970.224.6134- fax
fogov.com
Combustion Safety Test Compliance form
Replacement of Natural Draft Appliances in Existing Houses p�
Home Owners Name: Permit Number: F)
Address:_ Z —12 -7 13-h , (.5Cl — kJ G} VCC n Tele: "I 7 0 — qZ o - / 6C(
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: Allen Service
License Number: MP-4
Technician Name (print): CPH>ilcE r=v (LC5 j 6 -- Date: 9 .r, 11 d�
Technician Signature: Cps ,1%r Tele:
Appliance Tested: Ua-56t2 H G✓a I L:�ll.. Model #: 6 S b - So - 0 r'jr `iOv
Appliance Replaced: L1 HC ' 115Model #: 30! S 3 1--1 Y
STEP 1: Worst Case Conditions Test
Spillage/Backdr Duration (in seconds): Carbon Monoxide (parts per million):
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.conr/building/gr•eenclasses.plip
New form 3-16-2016