HomeMy WebLinkAbout701 Stoddard Dr - Special Inspections/Combustion Safety - 08/07/20171/25/2JU75-2017900MAMFXPT TO: 19702246134 FR0M9g4jaAj07234 T-885 F 0P 1e' F-11e41
lanning, Development & Transportation Services
Cat C f /� Community Development a Neighborhood Services
y V 281 North College Avenue
ort Collins Ro.Box 880
Fort Collins, CO 80522,0580
970.06.2740
970 224.813a- fax
fcgov cam
Combustion Safety Test Compliance Form
Replacement of Natural Draft Appliances in Existing Houses
Home Owners Name: �7 Permit Number:A 7 -
Licensed Contractor: v,7v of
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:
Technician Name (print): Date:
Technician Signature:
Appliance Tested: _ �/LAy4el- Model #:
Appliance Replaced: ziy/� Model #:
H1309
Tele:
STEP 1: Worst Case Conditions Test ,r
SpillageBackdr Duration (in seconds): Carbon Monoxide (parts per million):
Pass Fail (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
I certify that I an
-veOwner's Name
c7G Owner's
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