HomeMy WebLinkAbout215 Locust St - Special Inspections/Combustion Safety - 03/09/2018City of
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. corn
Combustion Safety Test Compliance Form
Replacement of Natural Draft Appliances in Existing House
Home Owners Name: �% � � L e,Il %V' s�_ Permit Number:
Address: Z./ 5 zevy&yS�— 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: License Number:
Technician Name (print):
�/ �A_ // & Date: 3�
Technician Signature:
Appliance Tested:
Appliance Replaced:
#: G"////
Model #:
STEP 1: Worst Case Conditions Test
Spillagef ack aft Duration (in seconds): Carbon Monoxide (parts per million): _ 3
Pass Fail (Technician must test under Natural Condition ` , ailed")
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
STEP 3: Home Owner
I certify that 1 a/el Owncr's NameOwner's Signa
until test passes under Natural Conditions.)
er of the above listed property.
Date
In the even�/Ehat my appliance has failed a Combustion Safety "rest under worst -case
conditio I hereby acknowledge that I have received a combustion appliance safety
informa n sheet. (initial)
Further information can be obtained at www.fcgov.com/building/greenclasses.php