HomeMy WebLinkAbout412 ROBIN CT - SPECIAL INSPECTIONS - 8/28/2017Planning, Development & Transportation Services
CitQd Community Development & Neighborhood Services
YN���ess��� 281 North College Avenue
,. �Ft�lirt Colts reis P.O. Box 680
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97Collins.80522.0580 ti 97D.416.2740
970.224.6134- fax
(cgov.com
Combustion Safety Test Compliance Form
Replacement of Natural Draft Appliances in Existing Houses
Home Owners Nae: �—n PC---r-,
mOY\ Permit Number: 4 /7e-y2
Address: Y(-/ x Tele: Ia 6) q"7O 71
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: Allen Service
Technician Name (print):
Technician Signature:
License Number: IVIP-4
Date:
Tele:
Appliance Tested: fin% f � Model #: 6—,"5 t
Appliance Replaced: I/✓ 2q Model #: �G '
STEP 1: Worst Case Conditions Test G �- (�
SpillageBackd aft Duration (in seconds): 30 Carbon Monoxide (parts per million): iS
Pass Fail (Technician must test under Natural Conditions if "Failed')
Technician's recommendations to correct 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 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.coin/building/greenclasses.php
New form 3-16-2016