HomeMy WebLinkAbout1120 City Park Ave - Special Inspections/Combustion Safety - 02/09/2017Planning, Development & Transportation Services
CcmMunity De"lopmeM 8 Nelahherhood Service!;
eat North College Avenue
P.O. Box 680 `
Port Co1Nns, Co aos22.0680
970.479.274E
4.6134 fax
kgov.
Combustion Safety Test Compliance Form
Replacem
e
nt of Natural
Draft Appliances in Existing Houses
Rvlanz
Home Owners Name: /L wQ 0 Permit Number:
Address: CsI r ale: -
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: License Number:
Technician Name (print):
G Date:
Technician Signature: -r Tele:
gig
Appliance Tested: Model 4:g6 2(g) !;�:6 tJ
Appliance Replaced: Model #:
STEP 1: worst Case Conditions Test
Spillage Duration (in seconds): i Carbon Monoxide (parts per million):
Passs/�. Fail (Technician roust lest under Natural Conditions if "Failed")
Technician's recommendations to correct tested appliance #'enure: .
STEP 2: Natural Conditions Test
Spil6geBackdraft Duration (in seconds): Carbon Monoxide (parts per million):
Pass Fail
(Failed test requires corrections until test passes under Natural CondWns.)
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/gmenclasses.php