HomeMy WebLinkAbout1015 Elgin Ct - Special Inspections/Combustion Safety - 04/16/2018 (2)•
Planning. Development & Transportation Services
Community Development & Neighborhood Services
281 North College Avenue
P.O. Box 580
Fort Coilins, CO 30522.0580
970.416.2740
970 224.6134- fax
f�gov.wrn
Combustion Safety 'Pest Compliance Form
Replacenngnt of Natural Draft Appliances in Existing Houses
1
Home Owners Name: <' = �> Permit Number: ' I ` 03 O 13
Address: i' f ( r.; 1 Tele: ) r ' (` & � F i
Licensed Contractor:
I hereby attest that I have performed the following Combustion Safety Pest in accordance with Fort
Collins Combustion Safety Test Guide Version 5, February 2012.
Company Name: Allen Service License Number:
Technician Name (print): �� �`:i`t %�1 Date:
MP-4
fechnician Signature: , Y / ^, Tele: 1 v "
Appliance Tested: V Model 4
Appliance Replaced: l�� / Model
STEP 1: Worst Case Conditions Test
�s 6
;i - / -
-H 1-k1/4
� 5-06
Spillage/Backdraft Duration (in seconds): % Carbon Monoxide (parts per million): % G
Pass NV// Fail (Technician must test under Natural Conditions if "Failed')
Technician's recommendations to correct tested appliance failure:
STEP 2: Natural Conditions Test
Spillage/Back raft Duration (in seconds). Carbon Monoxide (parts per million): t�
Pass Pail
(Failed test regrti+-es correctiotts until test passes under Natural Conditions.)
STEP 3: Home (honer 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, 1 hereby acknowledge that I have received a combustion appliance safety
information sheet. _ (initial)
Further information can be obtained at www.[cgov.conelbuilding/,n•eeneIasses. php
New form 3-16-2016