HomeMy WebLinkAbout821 Benson Ln - Special Inspections/Combustion Safety - 06/14/2018From
06/14/201a Oa 07 #009 P 001/001
Planning, Development & Transportation Services
It �l Community Development & Neighborhood Services
Fort Collins rt Box5g FCollege Avenue
Fort Collins CO 80522 0580
970 416 2740
970 224 6134 fax
fcgov com
Combustion Safety Test Compliance Form
Replacement of Natural Draft Appliances in Existing Houses
Home Owners Name �: Y / 7y1 Permit Number
Address. '60- s.�r-, Tele `1' 7o a3i. L 7 L
Licensed Contractor (3 Gtil 5o N Z- I�
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
Technician Name (print)
Technician Signature _
Appliance Tested t-,.i
Appliance Replaced
License Number
Date 2-U �S
Tele
Model # X&e/2-t4,!a l[f u
Model #
STEP 1 Worst Case Conditions Test
SpillageBackdraft Duration (in seconds) 190 Carbon Monoxide (parts per million) (�D
Pass Fail (Technician must test under Natural Conditions if "Failed")
Technician's recommendations to correct tested appliance failure
STEP 2 Natural Conditions Test
SpillageBackdra$ Duration (m seconds) ��_ Carbon Monoxide (parts per million) d
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 (print)
Owner's Signature
Date
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