HomeMy WebLinkAbout1550 Blue Spruce Dr - Special Inspections/Combustion Safety - 03/07/2018T
Planning, Development & Transportation Services
Community Development & Neighborhood ServlCes
281 North College Avenue
PA. Box SIM
ins Fort Collins, CO 80522.0580
970.418.2740
9-0 24.6134- faX
logov.com
Combustion Safety Test Compliance Form
.Replacement of Natural Draft Appliances in Existing Houses
Owners Name: A, , 4 14/` .2 LrPermit Number: 2
99: I � A �ut S der c �f Tele: ql-0
sensed Contractor:
I hereby attest that I have performed the following Combustion Safety 'lest in accordance with Fort
Collins Combustion Safety Test Crude Version 5, February 2012.
Name: License Number:
?/rn Name (print): � Date: _
n Signature: Tele:
Tested: nx,±r 0 �! p
Replaced:
Model #:
X 1: Worst Case Conditions Test
lageBackdraft Duration (in seconds): Carbon Monoxide (parts per million): S
Pass Fail (Technician must test under Natural Conditions if "Failed")
uucian's recommendations to correct tested appliance failure:
2: Natural Conditions Test
;eBackdraft Duration (in seconds)
Pass Fail
Carbon Monoxide (parts per million):
(Failed test requires corrections until test passes under Natural Conditions.)
3: Home Owner. Signature
✓ that I am the legal owner gf ft
Name (print)
Signature
above listed property.
Date .3 - %- /A
event that my appliance has failed a Combustion Safety Test under worst -case
lions, I hereby acknowledge that I have received a combustion appliance safety
ration sheet.. (initial)
Further information can be obtained at www.fogov.com/building/greenclasses.php