HomeMy WebLinkAbout139 Pearl St - Special Inspections/Combustion Safety - 09/28/2016Planning, Development & Transportation Services
CityO g Community Development & Neighborhood Services
i 281 North College Avenue
®rt Colli n s P.O. Box 580
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: n 1 ,X-. Permit Number:
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.
Company Name: C3• ". Cjt� w,U License Number:
Technician Name (print): Date: 9.z%,- tb
Technician Signatur
Appliance Tested: �rkec — Model #:
Appliance Replaced: Model #:
Tele:
STEP 1: Worst Case Conditions Test
SpillageBackdraft Duration (in seconds): 3 Carbon Monoxide (parts per million): t
Pass A 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.fcgov.com/building/greenclasses.pbp