HomeMy WebLinkAbout928 W LAKE ST - SPECIAL INSPECTIONS - 12/22/2017Planning, Development & Transportation Sery
Community Development&Neighborhood Services
City f— 281 North College Avenue
F6rt mod_ olti nS . Fort Collins8 CO 86522.0580
970.41&2740
970,224 6134- fax
fcgov con?
Combustion Safety Test Compliance Form
Replacement of Natural Draft Appliances in Existing Houses
Home Owners Name: R r%� Penn
it �!? Pi Pet Number: C _ °1:70 6� 7
Address: f7� b ��i—y 7 J C, C,y ' 0511 Tele: 97D —,7K-7 - / 3 73
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 License Number: MP-4
Technician Name (print}: e� �� JV\ Date: $ '
Technician Signature: / �. % Tele:
Appliance Tested: Wd Model #:
Appliance Replaced: Model #: ��— ��"%��,f✓
STEP 1: Worst Case Conditions Test (�
Spillage/Back aft Duration (in seconds): Carbon Monoxide (parts per million): 6
Pass Fail (Technician must test under Natural Conditions if "Failed' j
Technician's recommendations to correct tested appliance,failure:
STEP 2: Natural Conditions Test
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
New form 3-16-2016