HomeMy WebLinkAbout5030 Saffron Ct - Special Inspections/Combustion Safety - 01/30/2018Planning, Development & Transportation Services
City of community Development & Neighborhood Services
tat North Collcyo Avr:nue
,-,Fort Collins P.Oeoxsao
Fort Collins, CO 8(M2.0530
✓/ �' ' I 970..2740
970.22c224..613.1-fax
rVv 1cgov.com
Combustion Safety Test Compliance Form
Replacement of Natural Draft Appliances in Existing Houses
/ t Home Owners Name: 514,544 Csi t e..rL Pcrmit Numbcr: 12
Address: ) 0 10 S PO A C-t- Tele:.
I..icensed Contractor:
1 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: unj ���UIv1,��in� `. MLU i 'License Number:
Technician Name (print): Ptj' t 5e-A6U7 Date:
Technician Signature: Tele:
Appliance Tested:
Model #:
Appliance Replaced: ���C� \A Model #:A (p 5_(0— B �)
STEP 1: Worst Case Conditions Test
Spillage/Backdraft Duration (in seconds): � Carbon Monoxide (parts per million):
Pass � Fail (Technician must test under rVatural 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 raider Natural Conditions.)
STEP 3: Home Owner Signature
I certify that I am the legal owner of the above li
Owner's Name (print)
Owner's Signature _
Date / — !;I) —
In the event that my appliance has failM a Combustion Safety Test under worst -case
conditions, I hereby acknowledge that I have received a combustion appliance safety
information sheet. (initial)
Further infortation can be obtained at www.fcgov.coin/building/greenclasses.php