HomeMy WebLinkAbout329 Roosevelt Ave - Special Inspections/Combustion Safety - 01/19/2018Planning, Development & Transportation Services
City of
f Community Development & Neighborhood Services
C 1//�� 281 North College Avenue
F6r} Collins
P.O. Box580
` v` t 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: //ZZAAY Permit Number:
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: �p ,mil License Number:
Technician Name (print): Date:
Technician Signature: 0.0Tele:
Appliance Tested: `%�Model #: f/I/ -49U
Appliance Replaced: ZWdel #: G — Q/( - 00
STEP 1: Worst Case Conditions Test
SpillageBackdraft Duration (in seconds): 3/ Carbon Monoxide (parts per million):
Passy Fail (Technician must test under Natural Conditions if "Failed')
Technician's recommendations to correct tested appliance failure:
STEP 2: Natural Conditions Test
SpillageBackdraft 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 �roperty.
Owner's Name (print) IT. %t,
Owner's Signature
Date ( I 1
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.fcgov.com/buildinWgreenclasses.php