HomeMy WebLinkAbout2631 Antelope Rd - Special Inspections/Combustion Safety - 02/24/2017From:
02/27/2017 05:15 #516 P.001/001
Planning, Development & Transportation Services
Cityg Community Development & Neighborhood Services
sty Of I 281 North College Avenue
F®■ t Collin■qe ■s P.O. Box 580
Fort Collins. CO 80522.0680
970.416.2740
i 970.224.6134• fax
tcgov.com
CombustsJ/aety Test Compliance Form
Replacement of Naaft Appliances in Existing Houses
Home Owners Name: ��4� Permit Number: g\1p}j—T333't- Pjllppl�
Address:1:MIQ tC" 1;�Zh 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: 3
Technician Name (print):
Technician Signature: s
Appliance Tested:
Appliance Replaced:
License Number:
Model #:
Model #:
Date:
STEP 1: Worst Case Conditions Test
Spillage/Backdraft Duration (in seconds): &0 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
1 certify that 1 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