HomeMy WebLinkAbout2927 Stonehaven Dr - Special Inspections/Combustion Safety - 07/14/2017Planning, Development & Transportation Services
City Of Community Development & Neighborhood Services
F`ort Collin I�i P 0BoNorth College Avenue
Box 580
Fort Collins, CO 80522 0580
970A18.2740
970 224 6134- fax
Iegov com
Combustion Safety Test Compliance Form
Replacement of Natural Draft Appliances in Existing Houses
Home Owners Name- 6-wo/� iC, fL Permit Number•
S+o _e _ , v
Address: � Z 7 ti � Cm 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: _ r o.- i)1V4-nb;,1q License Number- M (� - !�T 7
Technician Name (print). ' 61114
N'l Date 7- , U-
//7
Technician Signature (ywr �r l Tele
Appliance Tested: Model #• Pr D (r S D— 3$ N RyiI y
Appliance Replaced.
Model
STEP 1: Worst Case Conditions Test
SpillageBackdraft Duration (in seconds)- %//Z Carbon Monoxide (parts per million): /j
Pass /' Fail (Technician must test under Natural Conditions if "Failed")
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 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 (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