HomeMy WebLinkAbout901 S TAFT HILL RD - SPECIAL INSPECTIONS - 1/26/2018 (2)Planning, Development e-- TramsportaUon Services
_ ? Community Development € tlreightrorhood Services
zi'°' '• J F ` 11 281 North CoQege Avenue
P.O. Box56o
Fort Coffins, CO 805220560
'j= z 870A16.2740
870.224.6134- itx
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Combustion Safety Vest Comphance Form
Replacement of Natural Draft Appliances in Existing Houser.
Home Owners Name: �� - f nkeX OC Ise, Permit Number g oo c)�ps4
Andress: q0t S . Ta�-4 H111 Rra Tele: �•Gig�• �ia�i 1
Licensed Contractor:
I hereby attest that I have performed the following Combustion Safety Test in accordancewith Fort
Collins Combustion Safety Test Guide Version 5, February 2012.
Company Name: 1 5 License Number. MP-15
Technician Name (print): rD Date:
Technician Signaturest: Tele:
Appliance Tested Model #:
Appliance Replaced:
Model #:
STEP 1: Worst Case Conditions Test
Spitlage/Backdraft Duration (in seconds): Carbon Monoxide (parts per million):
Pass Fail (Technician angst test under Natarat Conditions tf "Fatted")
Teehmician's recommendations to correct tested appliance hihue:
STEP 2: Natural Conditions Test
SpillawdBackdraft Duration (in seconds): Carbon Monoxide (parts per million):
Pass Fail
(Failed test requires comedians until tesipasses under Nahmd Conditions.)
STEP 3: Home Owner Signature
I ceftify that I am the legal owner of the above listed property.
Owner's Name (print)
Owner's Signature
Date
In the event that my apples has faded 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.comtbailding/greenclassm php