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HomeMy WebLinkAbout820 Merganser Dr - Special Inspections/Combustion Safety - 02/22/2018Planning, Development & Transportation Services Community Development & Neighborhood Services 281 North College Avenue P.O. Box 580 Fort Collins. CO 80522.0580 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: b ill leyo r Qom© Permit Numbel 0(Q S� Address: 9. - ��) SPACC J 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: Technician Name Technician Signa Appliance Tested Appliance Replai STEP 1: Worst Case Conditions Test SpillageBackdraft 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 �8 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