HomeMy WebLinkAbout420 S LOOMIS AVE - SPECIAL INSPECTIONS - 3/21/2018Planning, Development & Transportation Services
Clt Y I Community Development & Neighborhood Services
281 No, Cdiege Avenue
F6rt Coltins
P.O. Box 580
Fort Collins, CO 84522.0580
970.416.2740
970 224 6134- fax
t kgovxorn.
Combustion Safety Test Compliance Form
.Replacement of Natural Draft Appliances in Existing Houses
Home Owners Name: t �1 MOM 11 Permit Number
— U allele: CG 6I(�J� I i
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: Fort Collins Heating and Air License Number: H1309
Technician Name (print): Date: �
Technician Signature: 6 'rele:
Appliance Tested: g ��iModel #:
Appliance Replaced: Model #: jZMS0 04 uV 1 y Q
r STEP 1: Worst Case Conditions Test
SpillageBackd ft Duration (in seconds): Carbon Monoxide (parts per million):
Pass Fail (Technician must test, under Natural Conditions if "Failed')
a�
Technician's recommendations to correct tested appliance failure:
STEP Z: Natural Conditions Test
SpillageBackdraft Duration (in seconds): Carbon Monoxide (parts per million):
Y,
Pass Fail i C
(Failed test requires corrections until test passes "under Natural Conditions.)
STEP 3: Home Owner Signature
I certify that I am the legal owner of the above listed property.
Owner's Name (print) 1300 A&t )4Z 4LL
-4
Owner's Signature :1 Date z
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.fc"gov.com/building/greenclasses.php