HomeMy WebLinkAbout901 S TAFT HILL RD - SPECIAL INSPECTIONS - 1/26/2018,max y � �' _L
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Conmcmrtq Develop:Znent & Neighborhood Services
281 Noth College Avenue
PA BOX 589
Fort Collins, Co 8o522.058o
570.4162740
97D-224.6134- tax
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Combustion Safety Test Compliance Form
Replacement of Natural Draft Appliances in Fisting Houses
Home Owners Name: 1 r t - F C\k E, O C 1 St✓ Permit Number. ;2J
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 S, February 2012.
Company Name: t t � 0� License Number. _ .. M9-15
1 J
Technician Name (print): Date:
Technician Signature: _ Tele: Ci'10 XA'b(A- I (o (A
Appliance Tested: [A) Model #
Appliance Replaced:
Model
STEP 1: Worst Case Conditions Test
SpillageBackdraft Duration (in seconds): Z Carbon Monoxide (parts per million): J j
Pass —4— Fail ('Technician must test under 1 yabrral Conditions if "Failed7D)
Technician's recommendations to correct tested appliance failure:
STZP 2: Natural Conditions Test
Spillage/Backdraft Duration (in seconds): Carbon Monoxide (parts per million):
Pass Fart
(Failed test requires corrections until test passes under Natural Conditions.)
STEP 3: Home Owner Signature
I clarify that I am the legal owner of the above listed property.
Owner's Name (print)Lr
Owner's Signature Date U
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/buildingjgreenclasses.php