HomeMy WebLinkAbout2225 Shawnee Ct - Special Inspections/Combustion Safety - 02/20/2018Planning, Development & Transportation Services
Community Development 8, 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 Safe Test Compliance Form Z ��
ty ty��
Replacement of Natural Draft Appliances in Existing Houses
'2.1'- �f )� -t��� `t Permit Number: :
Home Owners Name.
Address �(`'_�. 1.�. iif �i ` IC -J
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.
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Company Name: 1 License Number: ? Ud
Technician Name (print):
Technician Signature: r
Appliance Tested: L1,1
Appliance Replaced:
Date. 2.
Tele:
Model #:
Model #: 4(/ j
STEP 1: Worst Case Conditions Test
Spillage/Backdraft.13bration (in seconds): Carbon Monoxide (parts per million):
Pass _�,Z Fail (Technician must test under Natural Conditions if "Failed")
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 corrections until test passes under Natural Conditions.)
STEP 3: Home Owner Signature
I certify that 1 am the
Owner's Name (pri
Owner's Signature
In the event that my appliance has failed a Combustion Safety Test under worst -case
conditions, I hereby, cknowledge that I have received a combustion appliance safety
information sheep., (initial)
Further information can be obtained at www.fc,lov.com/building/greenclasses.php