HomeMy WebLinkAbout1550 Blue Spruce Dr - Special Inspections/Combustion Safety - 03/05/2018City ob
Fort Collins
Planning, Development & Transportation Services
Community Development & Neighborhood services
281 North Caieye Avenue
P.O. Box 580
Fort Collins, CO 80522.0680
970.418.2740
870.224.6134-fax
kgov.com
Combustion Safety Test Compliance Form
Replacement of Natu Draft Appliances in Existing Houses
Home Owners Name: / ve.i ,1r C-I'rf Permit Number:
Address: I J'SO .4 Tele: 170 4N;e ,ZY([ rl
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:
Technician Name (print):
Technician Signature:
Appliance Tested:
Appliance Replaced:
STEP 1: Worst Case Conditions
SpillageBackdr ft Duration (in se
Pass Fail (Te
Technician's recommendations to
STEP 2: Natural Conditions Test
SpillageBaekdraft Duration (in sec
Pass Pail
(Failed test requires corrections
STEP 3: Home Owner Signature
I Certify that I am the leg=owner
Owner's Name (print)
Owner's Signature
License Number:
`7rt.J� Date:
Tele:
Model #:
Model
3 Carbon Monoxide (parts per million): �J
i must test under Natural Conditions if "Failed")
tested appliance failure:
Carbon Monoxide (parts per million):
test passes under Natural Conditions.)
above listed property.
I,,,- S 7 o "l
Date `1' S-` / S5
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.fegov.com/building/greenclasses.php