HomeMy WebLinkAbout5620 Fossil Creek Blvd - Special Inspections/Combustion Safety - 08/18/2017Planning, Development & Transportation Services
Ci�o Community Development & Neighborhood Services
�( 281 North College Avenue
650
rt C®[lens Fort Colli se CO 80522.0580
970.416.2740 2
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970.224.6134-fax V
fcgov.com
Combustion Safety Test Compliance Form
Replacement of Natural Draft Appliances in Existing Houses
Home Owners Name: 0-Q2 IA 5 k g f AV P Permit Number: 7 `�
Address: k5% — d 6tE '%WO ' Tele: -70Q (a Lo . ti
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): Date:
Technician Signature: / Tele: � D
Appliance Tested:
Appliance Replaced:
Model
Model
STEP 1: Worst Case Conditions Test
SpillageBackdraft Duration (in seconds): Carbon Monoxide (parts per million): ob3
Pass -><' Fail (Technician inust test under Natural Conditions if "Failed')
Technician's recommendations to correct tested appliance failure:
STEP 2: Natural Conditions Test
SpillageBackdraft Duration (in seconds): -P Carbon Monoxide (parts per million): ,
Pass X_ Fail
(Failed test requires corrections until test passes under Natural Conditions.)
STEP 3: Rome Owner Signature
I certify that I am the legal
Owner's Name
Owner's Signature
of the above listed property.
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 ,
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