HomeMy WebLinkAbout5915 Mars Dr - Special Inspections/Combustion Safety - 07/17/2018Planning; Development & Transportation Services
City
of
Community Development &,Neighborhood Services
North College Avenue
P.O.P.Box 580
Fort Collins, CO 80522.0580
970.416.2740
970.224.6134- fax
fcgov.cum 1
Combustion Safety Test Compliance Form -7/17//&
Replacement of Natural Draft Appliances in Existing Houses
Home Owners Narne: kafp Ate M e n Permit Number:
Address: (" ele:(q�) aQ5= Q Ll3 S
Licensed Contractor:Jr
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: NIP-4
Technician Name (print):, ,- C A A!�Q Date: A! �Q
Technician Signature: Tele:6 ig- ) gg53
Appliance Tested: �)�-( � a- Model -EQF '_�{S'?rrj
Appliance Replaced: A) n A-pr- 6e ck=(e4 - Model #:
STEP 1: Worst Case Conditions Test
SpillageBackdraft Duration (in seconds): Carbon Monoxide (parts per°million):
Pass Fail (Technician must test under Natt{ral Conditions if "Failed')
Technician's recommendations to correct tested appliance failure:
tio01 le
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: Horne Owner Signature
Icertify that I am the legal owner of the above listed property. ,
Owner's Name (Drint)X la (' C lv rh tu I C M e
Owner's Signature X 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.fcoov.corn/building/greenclasses.plip
New form 3-16-201.6