HomeMy WebLinkAbout409 Duke Ln - Special Inspections/Combustion Safety - 04/02/2018Planning, Development & Transportation Services
�`,� Q� Community Development&,Neighborhood Services
1 y 281 North College Avenue
t ulli n P.O. Box 580
Fort Collins, CO 80522.0580
970.416.2740
970.224.6134-fax
fcgov.00m
Combustion Safety Test Compliance Form
Replacement of Natural Draft Appliances in Existing Houses t
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Home Owners Name: �,y� e e 1�v/'S �`��u Permit Nmu�ber: Rc ��
4 Address: ef% 2 po tcc C,v Tele: 2 70 - ?a 3 03 S 7
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): Date: 1211 ,
Technician Signatur• . Tele: 12L4&LhO111
Appliance Tested: Model #: 7- LYae)
Appliance Replaced:�litJ �� Model #:
STEP 1: Worst Case Conditions Test
Spillage/Sackdraft Duration (in seconds): —� Carbon Monoxide (parts per million).
Pass -7" Fail (Technician must test under Natural Conditions if "Failed')
Technician's recommendations to correct tested appliance failure:
STEP 2: Natural Conditions Test
Spillage/Backdraft 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 ow f the abRXoJisted property.
Owner's Name (print)
Owner's Signature Date Y he
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.fccov.com/buildiiig/greenclasses.php
New form 3-16-2016