HomeMy WebLinkAbout437 DERRY DR - SPECIAL INSPECTIONS - 8/27/2017Planning, Development & Transportation Services
�0 �9 - Community Development & Neighborhood Services
281 North College Avenue
Fort Collins Fort Colli s8 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 ZA�.e t1 CT/ei%,{� Permit Number
Address �3�Ptoo -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 6^ ®G License Number
Technician Name (print) Date d�/.9? AP
Technician Signature l Tele 59R2 =ovzfo
Appliance Tested f1/r'Qrjr� Model #
Appliance Replaced IATA22/L Model #
STEP 1: Worst Case Conditions Test
SpillageBa'ckdraft Duration (inseconds) Carbon Monoxide (parts per million)
dr
Pass v 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)
Pass Fail
Carbon Monoxide (parts per million)
(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 abovelistedproperty / ,� /
Owner's Name (print) Wuxi (i �l/' ' N1171[ d
Owner's Signature Date g Z
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