HomeMy WebLinkAbout806 Laporte Ave - Special Inspections/Combustion Safety - 10/03/2016Planning, Development & Transportation Services
community Development S Neighborhood Services
281 North College Avenue
P.O. Box 580
Fort Collins, CO 80622.0580
970.416.2740
97a.224.6134-fax
fegov.com .
Combustion Safety Test ,Compliance Form
Replacement of Natural Draft Appliances in Existing Houses
Home Owners Name: �'"'` �l& Permit Number: Zllad&
Address: 1.&,,,,k ff., Tele:
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: License Number:
Technician Name (print): G 'Z"^"' ��'""" Date:
Technician Signature:✓�" `"
Appliance Tested: 11,10 ��Model #:
Appliance Replaced: 14 z 0 `b Model #:
Tele:
Gzyb II N
STEP 1: Worst Case Conditions Test
Spillage/Backdratt Duration (in seconds): 7> Carbon Monoxide (parts per million): L4
per$ Fail (Technician must test under Natural Condationv if "Failed")
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
(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 Iabove listed property.
Owners Name (print)
L9 U/1.1 V'd.� #VTSap& 0&0r 7+' /7 CCL5>
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.wratuilding/greenclasses.php