HomeMy WebLinkAbout516 Spring Canyon Ct - Special Inspections/Combustion Safety - 01/16/2018/16'Wft-Z018 �1' 411PMFXgT TO:19702246134 FROM87o4>jahg07234 T-To8 P.001MP: F-8891
Planning, Development & Transportation Services
FCtt of Community Development & Neighborhoo« Services
o. t Collins 281 North College Avenue
P.O, Box 680
Fort Collins. CO 80622.0580
970.416.2740
870.224.6134- fax
fcgov.cam
Combustion Safety Test Compliance Form
Replacement of Natural Draft Appliances in Existing Houses n
Home Owners Name: e
John 6YON Permit Number: I 800aO7
Address: EAD tpn Tele:
Licensed Contractor: W WeO6
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 Heating and Airy" License Number:
Technician Name (print): frl is k C4 _ Date:
Technician Signature:
Appliance Tested: w Model #:
Appliance Replaced: 4r/1G.C-e, Model #:
H1309
4"
Tele:
STEP 1: Worst Case Conditions Test
SpillageBackdraft Duration (in seconds): Carbon Monoxide (parts per million):
Pass —vfe—� Fail (Technician must test under Natural Conditions if `1Failed'7
Technician's recommendations to correct tested appliance failure:
STEP 2: Natural Conditions Test
SpillageBaekdraft 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
1 certify that I am the legal owner of the above listed properly.
kOwner's Name (pr
Owner's Signature
Date ) — A- / 8
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