HomeMy WebLinkAbout4425 WATERLEAF CT - SPECIAL INSPECTIONS - 12/4/2018Planning, Development & Transportation Services
City Of Community Development & Neighborhood Services
t Collins For North College Avenue
P.O. Box 580
Fort Collins, CO 80522.0580
970.416.2740
970.224.6134- fax
tcgov.com
Combustion Safety Test Compliance Form
Replacement of Natural Draft Appliances in Existing Houses
Home Owners Name: / ) ilv l 4 /� Permit Number: h I ,l ,i S'/ 7
Address:_ YLI)5- w"', / F Cr F.,r1C>//,,rro ?as), Tele: q 70_ V 227U
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: inr,1� RpAourcr, (enic- License Number. — j 176 C
Technician Name (print): 'Torn,Krrormr Date: 1,2- //- /Y
Technician Signature: �' /� Tele: 170 - (c/ 7- 440
Appliance Tested: Model #:44�O TO 6AVCa01
Appliance Replaced: t' w,G e Model #: M9 %IS E bt O I y 10 A
STEP 1: Worst Case Conditions Test {,
Spillage/Backdraft Duration (in seconds): V Carbon Monoxide (parts per million):
Pass Fail (Technician must test under Natural Conditions if "Failed'9
Technician's recommendations to correct tested appliance failure:
STEP l: Natural Conditions Test
Spillage/Backdraft Duration (in sbcone
Pass
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