HomeMy WebLinkAbout1557 Corydalis Ct - Special Inspections/Combustion Safety - 02/21/2018Ciof
Fort Collins
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: �O C' I�Ck-\ CQ-C permit Number: 20`7
-00
Address: CC1 C t S 7� Tele:(t� '2nF;-� L-
Licensed Contractor: co- �
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 Nam •
Technician Name (D ' tl: C)-\ r h
Technician Signature:
Appliance Tested:
Appliance Replaced:
License Number:
Date:
Tele:
Model
Model
STEP 1: Worst Case.Conditions Test 6_0Spillage/Backdr Hjuration (in seconds): �Carbon Monoxide (pails per miIIion)
Pass Fail (Technician must test under Natural Conditions if "Failed')
Technician's recommendations to correct tested appliance failure:
STEP 2: Natural Conditions Test
SpiI]age/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
I certify that I am the legal owner of the above listed property.
Owner's Name (print) ti 1( c�' C _' yr Owner's Signature Date 2— 2`Z
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