HomeMy WebLinkAbout820 Merganser Dr - Special Inspections/Combustion Safety - 05/03/2018Manning, Development & Transportation Services
Community Development & Neighborhood Services
City o It 281 North College Avenue
or ,� � _ F.O. Box 580
Fort Collins. CO 80522.0580
t� 970.416.2740
970.224.6134- fax
rcgov.cam
Combustion Safety Test Compliance Form.
Replacement of Na al Draft Appliances in Existing Houses
Home Owners Name: _ Permit Number- '!%
Address: 94710 4h-4on.5W Ue-+ 210 �Z 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 2012.
Company Name: "I11114%4'!7t Ze.f01`l( W License Number. MP- 4(9
Technician Name (print): (✓LIT5 LIV&JlfG Date:
Technician Signature: /—� Tele:
Appliance Tested: T (/e n/ Zy oir�L Model #:
Appliance Replaced: t 1 I << / Model #:_ (;- C.� — CIA qn2
STEP 1: Worst Case Conditions Test
Spillage/Backdraft Duration (in seconds): Carbon Monoxide (parts per million): 16
Pass V Fail (Technician must test under Natural Conditions if "Failed")
Technician's recommendations to convect 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 testpasses 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