HomeMy WebLinkAbout2701 Stover St - Special Inspections/Combustion Safety - 05/18/2018Planning, Development & Transportation Services
Gomsriunityr Development & Neighborhood Services
City of
�+�s 281 Norih College Avenue
F(5rt uotti ns P Q Box 580
Fort C�! Ilms CO 80522 0580
970A16 2740
-.rsa 970 22k 6134- fax
fcgov com
N
Combustion Safety Test Conphance Form
Replacement of Natural Draf Appliances in Existing Houses
_ S ~M &- 3
Hoene (Owners Name � iYl �. 'I Permit Number—
Addressi Tele
^, d � -,x =
I hereby attest that I have performed the following Combu
Collins Combustion Safety Test Guide V
Company Name Allen Service
Technician Name (print)
Technician Signature
Appliance Tested
Appliance Replaced
STEP 1 Worst Case Conditions Test
SpillageBackddraft Duration (in seconds) Y-5; Ci
Pass -1 Fail (Technician must test
Technician's recommendations to correct tested
STEP 2 Natural Conditions Test
Spillage/Backdi aft Duration (in seconds)
Pass Fail
(Failed test requires corrections until test passes
STEP 3 Home Owner Signature
I cer* that I am the legal owner of the above listed property
Owner's Name (print)
Owner's Signature
In the event that my appliance has failed a Combustion S
conditions, I hereby acknowledge that I have received a
information sheet (initial)
Further information can be obtained at www
New form 3 16 2016
Safety Test in aecoidance with Fort
5, February 2012
Number MP-4
_ Date
Tele
Monoxide (parts per million)
i Natural Conditions if "Faded')
Monoxide (parts per mullion)
Natural Conditions)
Date
Test under worst -case
bustion appliance safety
comfbwldmg/greenclasses php