HomeMy WebLinkAbout2318 Silver Trails Dr - Special Inspections/Combustion Safety - 01/26/2017!/1/2W01-YOR91Z't10PItSTFROW TO:19702246134 FROM :71987U4A4 h3 4 T-596'FVU4/oo8 4F-505
Planning, Development & Transportation Services
City of Community noveloament a Neighborhood Services
CollinsNorth College Avenue
Fo
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P.O. gOx 5a0
` l��_[�/l /� Fort Collins, CO 80522.0580
740 97022... .
970224.e13s- fax 1
fcgov.com
Combustion Safety Test Compliance Form
Replacement of Natural Draft Appliances in Existing Houses
Home Owners Name:
&-_�
Ny/F.,t, �l
permit Number: Q17 a6.3V
Address: -2 3J 9
51/ver
Tele:
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: A l'� Coif e License Ntnber:
Technician Name (print): Date:
Technician Signature: Tele:
Appliance Tested: t.,7/er r Model #:
Appliance Replaced: ModelJf
#:
STEP 1: Worst Case Conditions Test
Spillage/Backdra Duration (in seconds): !o Carbon Monoxide (parts per million):
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 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