HomeMy WebLinkAbout2609 Milton Ln - Special Inspections/Combustion Safety - 05/15/2018Planning, Development & Transportation Services
Community Development & Neighborhood Services
City of
6rt Collins 281 North College Avenue
P O Box 580
FFort Collins CO 80522 0580
�...` 970 416 2740
970 224 6134 fax
fcgov com
Combustion Safety Test Compliance Form
Replacement of Natural Draft
DraLt Appliances in Existing Houses
Home Owners Name 14Vj Qom' W�U�, Permit Number ��
Address e— n, -1 f 4, Tele 16 d - `%l i �T '
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 J_f License Number
Technician Name (print) �_ vl -T�j Date
Technician Signature 'XI a�
mbtV
S Ij_
Tele
T—
Appliance Tested%C /S '�.��i„ G��, Model # �raZ� J 4
Appliance Replaced
Model #
STEP 1 Worst Case Conditions Test
Spillage/Backdraft Duration (in seconds) Carbon Monoxide (parts per million) Ll
Pass /\- Fail (Technician must test under Natural 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 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