HomeMy WebLinkAbout2302 Owens Ave - Special Inspections/Combustion Safety - 11/06/2017Planning, Development & Transportation Services
Community Development & Neighborhood Services
281 North College Avenue
P O Box 580
Fart Collins. CO 80522 0580
970.416 2740
970 224 6134- fax
tcgov com
Combustion Safety Test Compliance Form
Replacement of Natural Draft Appliances in Existing Houses
Home Owners Name: SUM/& &vGus 14 Permit Number. 51707 44UI
Address:-Z30Z~Okl6.v S- �V1; . �tC-96S2$7 Tele: 307- 399- 997(0
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: %�.FT ck- yet v.t8w(o License Number:
Technician Name (print):
Technician Signature -
Appliance Tested
Appliance Replaced
STEP 1: Worst Case Conditions Test SpillageBackdraft Duration (in seconds): GC) .. 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) C-0— Carbon Monoxide (parts per million)
Pass X Fail
(Failed test requires corrections until test passes under Natural Conditions.)
STEP 3: Home Owner Signature
I certify that I am the legal owper of the above liste Tj ope
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 fegov com/building/greenclasses.php
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