HomeMy WebLinkAbout613 SKYSAIL LN - SPECIAL INSPECTIONS - 9/27/2016Planning; Development &7rd"" portation Services
City Community Developinent &..Neighborhood Services
281 North College Avenue
F_6rtlli!��IhnsFort Collins, CO 80522.0580
070:416.2740
970.224.61344 fax
tcgov.com
Combustion Safety Test Compliance Form
Replacement of Natural Draft Appliances in Existing Houses
Home Owners Name: , i� ( �y�nc,
/ / Permit i�tumber:.
Address: ��/� ; , l__t.� Tele: *Y I !
Licensed Contractor:
I hereby attest that I have performed the.following Combustion Safety Test in accordancewith Fort
Collins Combustion Safety Test Guide Version 5; February:2012.
Company Name: AIIen Service License Numb er; MP-4
Technician Maine (print)? Date: / . Z 7 f� r
Technician Signature: �; tom= ,�.1,�''� Tele: 1lSr;i i F cj
'Appliance Tested: l.y a-�(.�. /tea%1 Model.#:
Appliance Replaced;... Model #:
. `.STEP,1: Worst Case: Conditions Test
:Spillage/Backdraft Duration (in seconds): :Carbon Monoxide (parts. per million):
1
Pass. .. �.. Fail �, (Technician must test under Natural Conditions if Failed .
Technician'srecommendations to correct tested. appliance failure:
STEP 2Natural Conditions Test
Spillage/Backdraft Duration (in seconds) .-Carbon Monoxide (parts per. million).
Pass Fail
Failed test requires cor�r�ecdons until :test � asses under Natural. Conditions (p )
STEP 3: Home Owner Signature
I certify that.I am the legal owner of the above listed property.
Owner's Name (print) `s1 ! (, 2 r n
Owner's Signature ���i „ 'X� Date
�-
hi 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.fcgay.comJbuilding/greenclasses:php
New.form 3-16-2016