HomeMy WebLinkAbout1913 Meadowview Ct - Special Inspections/Combustion Safety - 12/20/2017Planning, Development & Transportation Services
CityCatof Community Development & Neighborhood Services
281 North College Avenue
Fort Collins P rt 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 & Az A 163,z!maup_ Permit Number
Address \0,\?) � nL�.���1���� �iC�r -`1 Tele Q2M
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 Number
Technician Name (print) f/ Date Z Z
Technician Signature 94.4— Tele
Appliance Tested Wovfiv' eaModel # (iZ SO t G_
Appliance Replaced Model #
STEP 1: Worst Case Conditions Test
SpillageBackdraft Duration (in seconds) b Carbon Monoxide (parts per million) �J
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) 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) ISM O v yi AjL./ WL-ov✓
Owner's Signature "
Date i
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