HomeMy WebLinkAbout1101 Baker St - Special Inspections/Combustion Safety - 03/31/2017Planning, Development & Transportation Services
Clty ®1 Community Development & Neighborhood Services
281 North College Avenue
Fort Collins PO Box580
Fort Collins, CO 80522 0580
970.416.2740
970 224 6134- fax
fcgov com
Combustion Safety Test Compliance Form
Replacement of Natural Draft Appliances in Existing Houses
Home Owners Name: ��///li Permit Number:%3Mee
Address: �[(�/,�,— �'� 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): Date: &c 1,3/ Zj%
Technician Signature: Tee: ,Q��—S9Y�rpQ?Z
Appliance Tested: /6 rd5Q L � Model #:��'
Appliance Replaced: /,1',�2L odel #:V 16 9-C. ?05:0/
STEP 1: Worst Case Conditions Test /
Spillage/Backdraft Duration (in seconds): p Carbon Monoxide (parts per million): AL
Pass 1/ Fai I (Technician must test under Natural Conditions 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 above listed property
Owner's Name
Owner's Signat
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/greenciasses.plip