HomeMy WebLinkAbout1700 Briargate Ct - Special Inspections/Combustion Safety - 01/23/2017/26/2JWj5-Z01701G:diAMP5AoM- TO:19702246134 FROM:710&V4E?5d34 T-548 PPEN01 1-284
Planning, Development & Transportation Services
c.l'zir of Il�L/1—� Community nevelopment a Neighborhood Services
fort Collin 1 �2, 281 Nonn GWlege Avenue
P.O. Box 500
Collins, CO 80522.0580
970
� 970.416.2740.
970.224.6134-lpx
kgov. corn
Combustion Safety Test Compliance Form
Replacement of Natural Draft Appliances in Existing Houses
Hfl ome Owners Name: Permit Number:
Address:
rt --
_Telex
Licensed Contractor: u
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: tT �IintS License Number. fl` (IOe(
Technician Name (print)_ r Date: q
Technician Signature: Telex (:{2
Appliance Tested: W Model 4:�L72Sdi �(f
Appliance Replaced: Model #iS`p TbA)
STEP 1: Worst Case Conditions Test 2
Spillage/Backdraft Duration (in seconds): sirc Carbon Monoxide (parts per million): 7
Pass _ 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
I certify that I am the legal own the abov listed property.
Owner's Name (print)
Owner's Signature Date t 2 3
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/greenolasses.php