HomeMy WebLinkAbout637 MANSFIELD DR - SPECIAL INSPECTIONS - 9/20/2016i IN
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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: �Cs ��/��°�c^� Permit Number: d-/v�C�-fd fie
Address: 6 3 7 F1,F- 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:, _., 7/ Y � License Number:
Technician Name (print): CU//�!l - � Date: �d
Technician Signature: z�� Tele:
2 I SEP 16 1.10PM
Appliance Tested: Ar f/i 6� %4 ii �v*-& Model #: e FC o C 7 0 %` 0 -!� lv ®W
Appliance Replaced: j`� UX k::j C— Model
STEP I.: Worst Case Conditions Test
Spillage/Backdraft Duration (in seconds): _ Carbon Monoxide (parts per million): �
Pass P Fail (Technician must test under Natural Conditions if "Failed')
Technician's recommendations to correct tested appliance failure:
STEP 2: Natural Conditions Test 7`0-c4"� 1/"54 z/7
Spillage/Backdraft Duration (in seconds): 5— Carbon Monoxide (parts per million): b�i,�
Pass 1--' 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) G�r��oL acvrl/ ��esr//G-uco�.��C
Owner's Signature //ii�.�_/� 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.co►n/building/greenclasses.php