HomeMy WebLinkAbout2319 Yorkshire St - Special Inspections/Combustion Safety - 09/08/2017Planning, Development & Transportation Services
Cl O1 Community Development & Neighborhood Services
281 North College Avenue
Fort Collins P.OBox580
Fort Collins, CO 80522.0580
970.416.2740
970.224.6134-fax
Icgov.com
Combustion Safety Test Compliance Form
Replacement of Natural Draft Appliances in Existing House
Home Owners Name:
Address: zg/!}i�/1,��%'C///1�
Licensed Contractor:
Permit Number:
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: �l%��� z�f
Technician Signature: Tele: ^ lv,—�r—a%apU
Appliance Tested: Model dZ ao
Appliance Replaced: Model #: zyz -gfa0
STEP 1: Worst Case Conditions Test /�
SpillageBackdraft Duration (in seconds): �L 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
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 A\�1
information sheet. (initial) C�
Further information can be obtained at www.fcgov.com/building/greenclasses.php