HomeMy WebLinkAbout1312 Constitution Ave - Special Inspections/Combustion Safety - 08/16/2018Planning, Development & Transportation Services
City.
S ® Community Development & Neighborhood Services
`C�f ®®®® 281 North College Avenue
F6,rt ILIs P.O. Box 580
Fort Collins, CO 80522.0580
970.416.2740
970.224.6134- fax
,t fcgov.com
Combustion Safety 'Pest Compliance Form
Replacement of Natural Draft Appliances in Existing Houses
Home Owners Name: K �� td Permit Number:161 813CRCA
Address \TW (nc\&k1\X 3, twt Tele:3t,}�to
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:5,& Q_.m6_� A-.L- G" - License Number:
Technician Name (print): Date:
Technician Signature: Tele: �1p- �43^dCJ�J
Appliance Tested: Model #: ( 0:rjo A) — y 7S
Appliance Replaced: \ja Model #:_LC,
STEP 1: Worst Case Conditions Test
SpillageBackdraft Duration (in seconds): 7d) Carbon Monoxide (parts per million): OZY
Pass ie� 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 k 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)
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