HomeMy WebLinkAbout3206 Bowie Dr - Special Inspections/Combustion Safety - 03/27/2018Planning, Development & Transportation Services
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Community Development & Neighborhood Services
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281 North College Avenue
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Fort Collins. CO 805220580
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: ;�'oQ ( &P1Permit Number: w2,//
3�
Address: 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: +rier eL License Number: h!' 25
Technician Name (print): Date: - Z —1
Technician Signature: n Tele: viYK`�Z
Appliance Tested:
Appliance Replaced:
Model #:
Model #:
STEP 1: Worst Case Conditions Test
Spillage/
Backaft Duration (in seconds) Carbon Monoxide (parts per million): Z�
PassFail (Technician must test under Natural Conditions if "Failed')
Technicicommendations to correct tested appliance failure:
STEP 2: Natural Conditions Test
Spillage/Backdraft Duration (in seconds):
Pass Fail
(Failed test requires eorr
STEP 3: Home Owner Sign
I certify that 1 am the legal ni
Owner's Name (pri
Owner's Sienat c
re
de (parts per million):
test passes under Natural Conditions.)
of the above listed property.
Date
In the event that my appliance has failed a Combustion Safcty 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.fcgov.com/building/greenclasses.php