HomeMy WebLinkAbout525 Affirmed Ct - Special Inspections/Combustion Safety - 02/26/2018Planning, Development & Transportation Services
City®� Community Development & Neighborhood Services
8 281 North College Avenue
Fort Collins P.O. Box 580
Fort Collins, CO 80522.0580
970..2740
970.224224.6134-fax
fcgov.com
Combustion Safety Test Compliance Form
Replacement of Natural Draft Appliances in Existing Houses
Home Owners Name: n�/a Son tr/o A 4nS e17 Permit Number:
i��
Address: ���J� i.,,>o( C�,. ?,96- oTele:
43/4? CIA o1;
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: ,%-1r e r7t^un ,t!�l ' gL License Number:
Technician Name (print): Yo Lf�. I2t� Date:
Technician Signature: Tele:
Appliance Tested: a) 1:�-+ef h e-,cLI Model #: 6 6 Y6 106 6- V G d
Appliance Replaced:
Model #:
STEP 1: Worst Case Conditions Test
SpillageBackdraftDuration (in seconds): —5�— Carbon Monoxide (parts per million):
/tD
Pass Unail (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 property.
Owner's Name (printfi ,' -N
Owner's Signature
J 9�°r1�ti'1
Date Z1 ?,�o I I t5
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/building/greenclasses.php