HomeMy WebLinkAbout2430 Cochetopa Ct - Special Inspections/Combustion Safety - 11/28/2017Fort Collins
Planning, Development & Transportation Services
Community Development 8: Neighborhood Services
281 North College Avenue
P O Box 580
Fort Collins, CO 80522 0580
970.416.2740
970 224 6134- fax
fcgov com
Combustion Safety Test Compliance Form '#,/y8 I
Replacement of Natural Draft Appliances in Existing Houses
Home Owners Nam���� Permit Number 61740 ld „ 7
Address- a��i� Tele: qCM,
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: License IN, A-2-3s
Technician Name (print . Date: a
Technician Signature: �bfN i wlnCtle to
Appliance Tested: �r-W f�,(j Wdt 5� Model #: �
Appliance Replaced: (J (ki t Se j (i ` 5 0 G Model #:_ b), S Imo_
STEP 1: Worst Case Conditions Test ��
Spillage/B aft Duration (in seconds): _ ,L Carbon Monoxide (parts per million)-
Pass 7 Fail (Technician must test under Natural Conditions iFailed
""
Technician's recommendations to correct tested appliance failure: f )
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 L
I certify that I am the legal owner of the above listed roperty.
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