HomeMy WebLinkAbout1500 Buckeye St - Special Inspections/Combustion Safety - 02/07/2017From:
02/08/2017 03:01 #494 P.001/001
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City of 2r ff
Fort Collins
Planning, Development & Transportation Services
Community Development & Neighborhood Services
281 Norlh College Avenue
P.O. Box 580
Fort Collins. CO 80522.0580
970.416.2740
970.224.6134-fax
/cgov.com
Combustion Safety Test Compliance Form
Replacement of Natural Draft Appliances in Existing Houses
Home Owners Name:_1 r �Permit Number:
Address: 'c�1- Tele: a1�4- 3113
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_,�xv NIci_\ Pe n� tY License Number: l� R!5S
Technician Name (print): � A L Date: a`1 LQ
Technician Signature: Tele: Gid �1y3 �GSc�
Appliance Tested: � �&,r Model #:
Appliance Replaced: F%.kc c.a c a Model #:
STEP 1: Worst Case Conditions Test *t--� Q otZ _ g . �& 1 0 a
Spillage/Backdraft Duration (in seconds): Carbon Monoxide (parts per million): _I ZZ 13
Pass K_- Fail (Technician must test under Natural Conditions if "Failed')
Technician's recommendations to correct tested appliance failure:
STEP 2: Natural Conditions Test ,� ��� ) d 1 ,W�
Spillage/Backdraft Duration (in seconds): /,�F Carbon Monoxide (parts per million): e it T 13
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 I have received a combustion appliance safety
information sheet. (initial)
Further information can be obtained at www.fcgov.com/building/greenclasses.php