HomeMy WebLinkAbout3706 Gullway - Special Inspections/Combustion Safety - 11/03/2017Planning, Development & Transportation Services
Community Development & Neighborhood Services
City of
ort Collins 281 North College Avenue
F P O Box 580
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 .2 Permit Number
Address ' 3 70 o 6� Gl/ / Tele
Licensed Contractor:
E/0-,7/-V73W
I hereby attest that I have performed the following Combustion Safety Test in accordance with Fort
Collins Combustion Safety Test Guide Version 51 February 2012
Company Name lltfoLicense Number
Technician Name (print) Date.
Technician Signature Tele 3Q�
Appliance Tested tA� Model # �e1�q— �/��/ /I, 1/[ 7
Appliance Replaced. / ��}✓ Model # (�' 209�
STEP 1: Worst Case Conditions Test
SpillageBackdraft Duration (in seconds) �3 Carbon Monoxide (parts per million) I—L
Pass —4<— 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/buildmg/greenclasses php