HomeMy WebLinkAbout2242 Clydesdale Dr - Special Inspections/Combustion Safety - 04/26/2016Planning, Development & Transportation Services
Community Development & Neighborhood Services
Qty 281 North College Avenue /
rt t,,.F%(0UInsFortCollins, CO 80522.0580 �&td�(
970.416.2740
970.224.6134- fax
fcgov.com
Combustion Safety Test Compliance For>«
Replacement of Natural Draft Appliances in Existing Houses
Hoene Owners Nance: ('I k ,r-r-S C j Permit Number t/6p -w %/
Address: rr Tele: A &i q A, p <Cz c)
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, Febivary 2012.
Company Name:. I p� (r' 11 License Number: —
Technician Name (print): 1-?? Gym _ Date: 4/ - ,-kZ^ - /,6
Technician Signature: ��---� Tele:-I.s 6-rSXL+,)L "d
Appliance Tested: �,/- („�_��-vim Model #:
Appliance Replaced:
Model #:
STEP 1: Worst Case Conditions Test
SpillageBackdraft Duration (in seconds): d,,b Carbon Monoxide (parts per million):
Pass � Fail (Technician must test under Natural Conditions if "Bailed')
Technician's recommendations to correct tested appliance failure:
STEP 2: Natural Conditions Test
SpillageBackdraft Duration (in seconds): Carbon Monoxide (parts per million):
Pass Fail
(Failed test requires corrections until testpasses 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)
Owner's Signature
Date
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.fcgov.com/building/greenclasses.php
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