HomeMy WebLinkAbout2960 W Stuart St - Special Inspections/Combustion Safety - 06/12/2018Planning,?evetopment & Transportation Services
Home Owners Name ErnAW 040
Address .49I40 W. S-tva.-t- St -
Licensed Contractor
I hereby attest that I have performed the following Combu
Collins Combustion Safety Test Guide U
Company Name Aden Service
Technician Name (print)
Technician S
Appliance
(,Y- J-/e,*,a
Permit Number R j g' a y 4 17
Tele
Safety Test in accordance with Fort
. 5, February 2012
Number -MP-4
Appliance Replaced Frr)a c Model #
STEP 1 Worst Case Conditions Test
4 SpillageBackdraft Duration (m seconds) Tito 0
/ PassyFail (Technician must test under Natural Conditions if "Failed ")
Technician's recommendations to correct tested appliance failure
Date
(parts per million) /`6
STEP 2 Natural Conditions Test
Spillage/Backdraft Duration (m 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 fatted a Combustion Safety Test under worst -case
11
conditions, I hereby acknowledge that I have received a combustion appliance safety
information sheet (initial)
Further information can be obtained at www fcgov"com/butldzng/greenclasses php
New form 3-16-2016