HomeMy WebLinkAbout4615 CHOKECHERRY TRL - SPECIAL INSPECTIONS - 10/2/20170 Planning, Development & Transportation Services
City of Community Development & Neighborhood Services
281 North College Avenue
Fort Collins P.OBox 580
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: Permit Number: 3�1p5?�3�1
Address: Ut"� ��t�p, -� 1 Tele: Zk;!)\-
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:
Technician Name (print):
Technician Signature:
Appliance Tested: —a
License Number: \
k Date: 9,` � n,
Tele: �L��
Model #:�alJ"[(o{�j-l�-�$
Appliance Replaced: k6."-� Model #:
STEP 1: Worst Case Conditions Test
Spillage/Backdraft Duration (in seconds): &6 Carbon Monoxide (parts per million): /7
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