HomeMy WebLinkAbout3430 Sam Houston Cir - Special Inspections/Combustion Safety - 04/02/2018Planning, Development & Transportation Services
City QI Community Development &.Neighborhood Services
��� North College Avenue
P.O.F(5rt Cons P.Box 580
Fort2, 86522.0580
970d16.16.2740
970.224.6134- fax
rcgov.com
Combustion Safety Test Compliance Form
Replacement of Natural Draft Appliances in Existing Houses
Home Owners Name:
Licensed Contractor:
Permit Number: FA66 7 (
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: Alien Service License Number: MP-4
Technician Name (print): (7 Date: 6
Technician Signature: Tele:
Appliance Tested Model #:
Appliance Replaced: el #: 6j5h
STEP 1: Worst Case Conditions Test /�
SpillageBackdraft Duration (in seconds): - �— Carbon Monoxide (parts per million):
Pass /"' 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
Owner's Name
Owner's Signature
In the event that my appliance ha f�l' ee Combustion Safety Test under worst -case
conditions, I hereby acknowledge that I have reeeivec(Ta combustion appliance safety
information sheet. (initial)
Further information can be obtained at www.fcgov.com/building/greenclasses.php
New form 3-16-2016