HomeMy WebLinkAbout4306 SHADOWBROOKE CT - SPECIAL INSPECTIONS - 10/26/2017Planning, Development & Transportation Services
Clt Of Community Development s Neighborhood Services
281 North College Avenue
Fort Collins P.O. Box 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: NIA J 14o t( is Permit Number:
Address: 4306 qoddw Bad ,Foe+ Gl(i}_ Co. jo!2b Tele: (170) yq3 S71 a
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: PR fnZk to/u� ``^� License Number: M ►° 2S-
v
Technician Name (print): n�TeF AI of Date: 1 d/ sl�1 7
Technician Signature: U•�ll 7 Tele:
Appliance Tested: ualry I. W I-v Model #: 1* P ro L1 So
Appliance Replaced: w of k k oo kv Model #: P r o Q S o- l Y n- M 0-
STEP 1: Worst Case Conditions Test
SpillageBackdraft Duration (in seconds): n Carbon Monoxide (parts per million): 90
Pass p 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): J9 dd
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