HomeMy WebLinkAbout901 GROUSE CIR - SPECIAL INSPECTIONS - 9/7/2017i/11/W-711-201T09i: 11AMART TO:19702246134 FRO149i�4jaA907234 T-5T4 PIMP: F-2151
e Planning, Development & Transportation Services
City/ Of ` Community Development a Neighborhood Services
251 North College Avenue
Col has P.O. Box 580
Fort Collins, CO 80522.0680
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: Permit Number:.
Address: �C?1,14 1? 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: Fort Collins Heating and Air License Number:
Technician Name (print): Date:
Technician Signature:
Appliance Tested: 4'll Model #:
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Appliance Replaced: lei Model------------
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STEP 1: Worst Case Conditions Test / /I
SpillageB ft Duration (in seconds): tj[/ Carbon Monoxide (parts per million):
Pass Fail (Technician .Host 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) 4!�
Owner's Signature
Date
In the event that my appliance hasYailed 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