HomeMy WebLinkAbout2946 Zendt Dr - Special Inspections/Combustion Safety - 02/28/2018Combustion Safety Test Compliance Form
Replacement of Natural Draft Appliances in Existing Houses
Home Owners Name: Q)"Atoo Permit Number:
Address: 29 H ZP.n �-) i 7 i gc) r-) ( Tele:
Licensed Contractor:
1 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 Air License Number: H 1309
Technician Name (print): Date
Technician Signature: -
Appliance Tested: �Av o Model #:
Appliance Replaced: v Model #:
2/21Vr5�
Tele:
STEP 1: Worst Case Conditions Test
Spillage/Backdraft Duration (in seconds): 3 O Carbon Monoxide (parts per million):1�
Pass V/ 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)
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.fegov.com/buiIding/greenclasses.php