HomeMy WebLinkAbout3707 Ashmount Dr - Special Inspections/Combustion Safety - 03/30/2018Planning, Development & Transportation Services
Community Development & Neighborhood Services
City.of f 281 North/College Avenue
Coi, �p P.O. Box-580
o��a Fort Collins, CO 80522.0580
970.416.2740
970.224.6134- fax
fcgov.com
Combustion Safety 'Pest Compliance Form
Replacement of Natural Draft Appliances in Existing Houses
Home Owners Name: c )1 L__ `��2U iJC� Permit Number: )L'3 C
Address: S] (P �l A�� F-t b�} r j7 0?, 1;'r (bi-L1 Z5 Tele: q 7a 221 9 U 10
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: (� RL� License Number:
Technician Name (print): - dAkv-�) Date: i% -
Technician Signature: Tele:97lb Tel°i Ofi257-
Appliance Tested: I> c—tAL Model #:���m ` l v��
Appliance Replaced: a ML— Lo Model #:
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 listed pfroperty.
Owner's Name (print 1 + 1 6NL
Owner's Signature Date 3
In the event that my apWance has failed a Combuoon 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/building/greenclasses.php