HomeMy WebLinkAbout1809 GOLDEN WILLOW CT - SPECIAL INSPECTIONS - 11/29/2017City of
F6rt CO«ii1S
Planning, Development & Transportation Services
t community Development & Neighborhood Services
281 North College Avenue
P.O Box 580
Fort Collins, CO 80522 0580
970 416 2740
970 224.6134• tax
lcgov com
Combustion Safety Test Compliance Form
Replacement or Natural Draft Appliances in Existing Ilousess �f'�
Home Owners Name: SCOTT MCINTOSH Permit Number: R' 3
Address:1809 GOLDEN WILLOW CT Tele: 970-204-1455
Licensed Contractor:
I hereby attest that I have performed the following Combustion Sarety Test in accordance with Fort
Collins Combustion Safety Test Guide Version 5. February 2012.
Company Name: NORTHERN COLORADO AIR, INC. License Number: H-837
Technician Name (print): �J LANCASTER Date: 11/29/2017
Technician Signature:_i!� Tele: 970-223-8873
Appliance "Tested: _WATER HEATER Model Il:� St7 y �/V
Appliance Replaced: FURNACE Model N: EL1 95UH1 1OXE60C
STEP 1: Worst Case Conditions Test '
Spillage/Backdraft Duration (in seconds): 0_ Carbon Monoxide (pans per million): —ilL3
Pass —Y\, Fai I (Technician must lest under Natural Conditions if "railed')
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
(railed test requires corrections until test passes under Natural Conditions.)
STEP 3: [tome Owner Signature
I certify that I am the legal owner of the above listed property.
Owner's Name (print) S-a" mcM rl-,
Owner's Signature _ r --- ""`- 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.Pcbov.com/buiIding/greenclasses.php