HomeMy WebLinkAbout1550 Blue Spruce Dr - Special Inspections/Combustion Safety - 02/12/2018Planning, Development & Transportation Services
.. ■ Community Development & Neighborhood services
Cl 0 281 North College Avenue
s Box 5eo
Fort Collins, CO60522.0580
FOrt° Clan
970,419.2740
970.224.6134-faxes6_�
kgov.com
Combustion Safety Test Compliance Form
Replacement
/of Natural Draft Appliances in Existing Houses
Home Owners Name: �jPi h p ��QjG' // Permit Number: 010 t
r,
Address: 5S a 3 L S per.. �� I a . u,, r #57 Tele: '7 O - yZ
Licensed Contractor:
I hereby attest that I have performed the following Combustion Safety Test in accordance with Fort
Collins Combustion Safety Test Guide Version S, February 2012.
Company Name:
License Number:
Technician Name (print): t7a.,, fl �... a av Date: T f i 'r
Technician Signature: ,Q Tele: 97P vvr $-y p7
Appliance Tested: L ,�,.,_..., �mrs� Model #: ,+.r^,Jo n
' T
Appliance Replaced: w.,.c:; /„�, Model
STEP 1: Worst Case Conditions Test
SpillageBackdraft Duration (in seconds): Carbon Monoxide (parts per million): 2.7
Pass _ Fail (Technician must test under Natural Conditions if "Failed' j
Technician's recommendations to correct tested appliance failure:
STEP 2: Natural Conditions Test
SpiIlageBackdraft 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.fogov.com/building/greenclasses.php