HomeMy WebLinkAbout6769 Antigua Dr - Special Inspections/Combustion Safety - 12/20/2016V
Fort Collin
Planning, Development & Transportation Services
Community Development & Neighborhood Services
281 North College Avenue
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: 11�01 ► ry Permit Number:
Address: CD -26 2 ,A-,,v�/� 11r} �bv��A��I _ 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.
L Company Name: !.1%�5, f,1.L,/�i� `L ense Number:—
Technician Name (print): Date: /Z- ;).0 lG
Technician Signature: Tele: -s:-lo/a iyeY
Appliance Tested: ` Model #: /
Appliance Replaced: -64-7 Model
STEP 1: Worst Case Conditions Test
SpillageBackdraft Duration (in seconds): -oX0 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): d Carbon Monoxide (parts per million):
Pass x 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