HomeMy WebLinkAbout2019 Creekwood Dr - Special Inspections/Combustion Safety - 10/24/2018Manning, Development & Transportation Services
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Community Development & Neighborhood Services
281 North College Avenue
P.O. Box580
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Fort Collins. CO 80522.0580
970.416.2740
970.224 6134- fax
fcgov.com
Combustion Safety Test Compliance ]Form DEC 1 1 Z016
Replacement of Natural Draft Appliances in Existing Houses
Home Owners Name: �,-e / Py?l,/ e i' Permit Number: p >I
Address: 2,0/ 1 (', P �t lc c �� TeIe:
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.
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Company Name: License Number:
Technician Name (print): /V ^ I/ C Date:
Technician Signature: ��_ ��}� Tele:
Appliance Tested: JUA "/ Model #: •Y (Xjo i mC UO
Appliance Replaced:
Model #:
STEP 1: Worst Case Conditions Test
Spillage/Backdraft Duration (in seconds): S Carbon Monoxide (parts per million): 'a I
Pass i 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, I hereby acknowledge that 1 have received a combustion appliance safety
information sheet. (initial)
Further information can be obtained at www.fcgov.com/buiIding/greenclasses.php