HomeMy WebLinkAbout3809 Big Dipper Dr - Special Inspections/Combustion Safety - 09/21/2018t & Transportation Services
FCity of t & Neighborhood Services
®" t C co) Ihn"'cia 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:
Licensed Contractor:
Permit Number: Q 190 � ,7
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): nr.aA Date:
Technician Signature: Tele:
Appliance Tested: Model #:_ GF4 LA 0-6 CT
Appliance Replaced: S-7w—null Model #: M �adXWIQ
STEP 1: Worst Case Conditions Test
SpillageBackdraft Duration (in seconds): 291 Carbon Monoxide (parts per million): j("a—
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): L, 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.fcgov.com/building/greenclasses.php