HomeMy WebLinkAbout2401 Cochetopa Ct - Special Inspections/Combustion Safety - 11/21/2017/221JVJj2-2o1T0�i:taMAMF&T TO:19702246134 FR0MgW4jaAj07234 T-31T P UPIMP: F-5041
Combustion Safety Test Compliance Form
Replacement of Natural Draft Appliances in Existing Houses
Home Owners Name: mr a- DAnA C<��7 � Permit Number�b�C(0�
Address: (- �1— v-%►eio� C�� Tele: �tj70T�cdr,,4
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: Fort Collins Heabng and Air License Number: H1309
Technician Name (print): �/� Date: /
Technician Signature: % ,iYT /. /- Tole:
Appliance Tested: / a mf Model #:
Appliance Replaced: cel- Model #:
STEP 1: Worst Case Conditions Test
SpillageBack Duration (in seconds): _ Carbon Monoxide (parts per million): 1-15_
Pass Fail (Technician must test under Natural Conditions if "Failed' j
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 testpasses under Natural Conditions.)
STEP 3: Home Owner Signature
I certify that I am the legal owner of the above listed property.
Owner's Name t) eon bgi�S
Owner's Signature t e -z— Date (� a'Zi 20 ( 7
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