HomeMy WebLinkAbout624 SKYSAIL LN - SPECIAL INSPECTIONS - 11/9/2017From:
01/16/2018 03:33 #870 P.001/001
Planning, Development & Transportation Services
E�f Community Development & Neighborhood Services
& 281 North College Avenue
Flirt � P.O. Box 580
aa�_ Fort Collins. CO 80521..0580
970.416.2740
970.224.6134- fax
7cgov.com
Combustion Safety Test Compliance Form
Replacement of Natural Draft Appliances in Existing Houses
Home Owners ame: (`�`��, Q�j Permit Number:
Address:�9),�_S�l_ C�ti� Y1 Tele:
Licensed Contractor:
1 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: s uey�QO Q a _ License Number:
Technician Name (print): Date:
Technician Signature:-- l % -`" Tele:IJ
g3 al�Sl
Appliance Tested: 14/✓r+_ L_ rj Model #:
Appliance Replaced: Model #:'y41/�I04�'gy�
STEP 1: Worst Case Conditions Test
Spillage/Backdraft Duration (in seconds): Carbon Monoxide (parts per million):
Pass —4- Fail (Technician must test under Natural Conditions if "Failed'q
Technician's recommendations to correct tested appliance failure:
STEP 2: Natural Conditions Test
Spillage/Backdraft Duration (in seconds): J_6L Carbon Monoxide (parts per million):
Pass 6K 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/greenelasses.php