HomeMy WebLinkAbout4436 STONEY CREEK DR - SPECIAL INSPECTIONS - 10/3/2017Planning, Development & Transportation Services
City Of Community Development a Neighborhood services
Fort Colli ns P.O.281 Box 580 College Avenue
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 b``Draft`` Appliances in Existing Houses
Home Owners Name: S►1zAtA " a- Um -A Iy (LC Permit Number:
Address: 4K 36 5fs, Tele:
Licensed Contractor:
I hereby attest that I have performed the following Combustion Safety Test in accordance with Fort
Collins Combustion Safety Test Crude Version 51 February 2012.
Company Name: Pryor P f t-m y, ti e License Number:
Technician Name (print): _ C a 5 Date:
Technician Signature:
MP-3g7
Tele:
Appliance Tested: L)a f-fr lea f-t/ Model #: (Z G Z,So 7'C N
Appliance Replaced:
Model
STEP 1: Worst Case Conditions Test
SpillageBackd/raft Duration (in seconds): 9 12- Carbon Monoxide (parts per million):
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): 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