HomeMy WebLinkAbout617 LOCUST ST - SPECIAL INSPECTIONS - 2/27/2018�eeEs E!?C, DG-cirt
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Community Qeirelopn:ent i i+ial hborhood Services
281 North College Avenue
r � Box 580
�rt �0 Fort
Fort Collins, CO 80522.0580
° 16.2740
-- 76 ct
970.224.6134-ie--
fcgov.com
Combustion Safety Vest Compliance Form
Replacement of Natural Draft Appliances in Existing Houses
Home Owners Name: 1) . ( nt1 Mo. S OCI Permit Number i✓ 1 f�0 119
Address: (e ('l t B (' t •�_ Tele: j 0.222. 217 0
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: IAan?[I LI no k License Number: _"9-1 g
Technician Name (print): f��r n Date: 2 - 2 '7 - Or
Technician Signature: — -- Tele: g•� 0 •�a • "j . ( a
Appliance Tested ��)oAzr ��,,� a Model #: C C Z 4
Appliance Replaced: C3o4e , Model #:
STEM 1: Worst Case Conditions Test
SpillageBackdrai3 Duration (in seconds): Carbon Monoxide (parts per million): /
Pass - Fail (Technician must test render Natural Conditions if "Fallen")
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
(Fafled test requires corrections unto test passes under Natural CondWona)
STEP 3: H08ne Owner Signature
I certify that I am the Iegal 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 aclmowledge that I have received a combustion appliance safety
information sheet (initial)
Further information can be obtained at www-fcgov.com/buikUnglgreenclasses.php