HomeMy WebLinkAbout820 Merganser Dr - Special Inspections/Combustion Safety - 03/23/2018Planning, Development & Transportation Services
Community Development & Neighborhood Services
City of IIs11 281 North College Avenue
�®r$` Coy` lins P.O. Box 580
'� Fort Collins, CO 80522.0580
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i��'8nsm.- 970.416.2740
970.224.6134-fax
fcgov.com
Combustion Safety Test Compliance Form .
Replacement of Natural Draft Appliances in Existing Houses
Home Owners Name: J ✓ Permit Number: Z ( S(,o
Address: Tele:
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 I ► 200,1,2.. q
Company Name: /ifs n n ,/Yi c �� License Number. / P- 4 � 1
Technician Name (print): s < -10`t1pvrXC Date:
Technician Signature: —v Tele(`j70
Appliance Tested: fo G �� ` Model #: CT C-13 - Yd - G/U--Z)
Appliance Replaced: < < < < Model #: "t'r-Ul VO
STEP 1: Worst Case Conditions Test
Spillage/Backdra 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.com/building/greenclasses.php