HomeMy WebLinkAbout2913 Eagle Dr - Special Inspections/Combustion Safety - 05/18/2018Planning, Development & Transportation Services
Cit� Od Community Development & Neighborhood Services
y GG 281 North College Avenue
Fort Collins P.O. Box 560
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
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Home Owners Name: —Jy I c, Permit Number: kO` 3 O 4
Address: 2g l3 ale J-„ Tele:
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: lAI —Vt — License Number. 736
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Technician Name (print): ru Date:
Technician Signature: Tele:
Appliance Tested: 6,04 j'c i f f 'peat f7er Model #:
Appliance Replaced: F2 bnc.LF. Model #:s� 1r�� a. +
STEP 1: Worst Case Conditions Test
SpillageBackdraft Duration (in seconds):_ Carbon Monoxide (parts per million):
Pass -/KL— 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 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