HomeMy WebLinkAbout820 Merganser Dr - Special Inspections/Combustion Safety - 04/12/2018 (2)Planning, Development & Transportation Services
community Development & Neighborhood Services
JURY of 261 North College Avenue
O. Box 580
® t W ns F ntins. CO, 80522.0580
970.416-2740
970.21' 4.6134- fax
rcgov.com
Combustion Safety Test Compliance Form _
Replacement of Natural Draft Appliances in Existing Houses
Home Owners Name: ' ��'1 Permit Number: O�POIp�
Address: S Zyt'' & q,,,, 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: ((� �u� SeF Ct. Co License Number.
Technician Name (print): d,�S M ,�'A t Date:
Technician Signature::)J Tele:
Appliance Tested: —(6 i7tF Model #:
Appliance Replaced: (< < ` < < Model #: �1 �T` �0 10CAV
STEP 1: Worst Case Conditions Test
SpillageBackdraft Duration (in seconds): CI Carbon Monoxide (parts per million):
Pass t/ Fail (Technician must test under Natural Conditions if "Failed")
Technician's recommendations to correct tested appliance failure:
STEP 2: Natural Conditions Test
Spiilage/Backdrafi 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.fegov.com/buildingtgreenclasses.php