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Fort Collins Residential Energy Code the g & zoning de Pt, of
AIR SEALING DISCLOSURE FORM Community Planning and Environmental Service
Zal N. Coffege Ave., P.O. Sax 5aO, Fort Collins, CO 80522
aid..'...—TR04� '
(Not applicable to E-STAR or ENERGY.SCORE rated homes) Voice: 970 221 0?60 FAX: 970 224 6134
Job address: / Ob
General contractor.
Air sealing contractor. �: �� --17A4sAc
Complete either Pan A or Part B .
Part A is to be signed by the air sealing contractor or representative of the general contractor.
Part S is to be signed by the blower door testing contractor or representative of the general contractor.
The "Slower Door Test Report" or equivalent documentation must be attached.
Please type or print,. except for the signature.
If components vary, mace multiple entries to describe them.
One copy of this form must be provided to the Sulding and Zoning Department prior to C. 0.
One copy of this form must be_provided to the original home buyer.
A. Prescriptive:.pa_ h..;(A>r..S:eal ng Chef..........::�...............::::....•::::.:::..::::.:::::::....:::::.:...........:........ ..... ...............................
INVe cer`siy that the air sealing requirements specified in the current City of Fart Ccifins Residential Snergy Cade
have been completed in this building, in accordance with the "Air Sealing Chec. iist" published by the Ctty of Fart Collins.
Person Certifying Job:
_Signature /��y��C Date- �•%S`—�
Susiness Firm: -,0,l7a,
Address:
1-D ut �._� n St O ��? Phone: gB1/
Me cartify that this building has met the air leakage performance threshold specified in the current Fort Collins
Residential Energy Code, in accordance with the "Slower Door Test Procedures" published by the City of Fart Collins.
Testing contractor.
Date of test
CFM50:
Volume:
ACH50:
Person Certifying Job:
Air flow through the blower door at 50 Pascals pressure difference (cfrri)
Volume of home (cu. fL)
Air change rate per hour at 50 Pascals pressure difference
ACI-f50 = (CFMeO x 60)1 Volume
The performance threshold ,or code compliance Is ACHS3
net exceeding 5.0 aa'h
Signature: Date:
Address:
Phone: