HomeMy WebLinkAbout2750 Catamaran Cv - Special Inspections/Combustion Safety - 08/14/2018Planning, Development & Transportation Services
F City Of ommunity Development & Neighborhood Services
281 North College Avenue
ort Collinsns P.OBox580
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: f A li lfe e % (i Permit Number: A lS U, 3
Address: , y6- ed.'i isr rtAel tG�c_ Tele: qr%O f L' i —o/, 77
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.n
Company Name: / License Number: ! '
10
Technician Name (print): %<- U,-,rn fin; S l:. Date:
Technician Signature: /.__ Tele:
Appliance Tested: j%i ,,ti( Model #:,1���
Appliance Replaced:
Model
STEP 1: Worst Case Conditions Test
Spillage/Ba'ckkdraft Duration (in seconds): Carbon Monoxide (parts per million):
Pass /x Fail (Technician must test under Natural Conditions if "Failed")
Technician's recommendations to correct tested appliance failure:
STEP 2: Natural Conditions Test
Spillage/Backdraft 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 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, 1 hereby acknowledge that I have received a combustion appliance safety
information sheet. (initial)
Further information can be obtained at www.fcgov.com/building/grecnclasses.php