HomeMy WebLinkAbout808 SNOWY PLAIN RD - SPECIAL INSPECTIONS - 8/24/2018Planning, Development & Transportation Services
Community Development & Neighborhood Services
City of � 281 North College Avenue
FOr ` Collins P.O. Box 580
Fort Collins, CO 80522.0580
970.49 8.2740
970.224.6134- fax
(cgov.com
Combustion Safety Test Compliance Form
Replacement of Natural Draft Appliances in Existing Houses
Home Owners Name: _Till �r_r �o� c� Permit Number:
Address: Aar Tele: 1C4q
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: �! License Number:
Technician Name (print): ,�,% -t�.r� Date:
Technician Signature: ��
Tele:
Appliance Tested: 7 a Model #:
Appliance Replaced:
Model #:
STEP 1: Worst Case Conditions Test
Spillage/Backdraft Duration (in seconds): Carbon Monoxide (parts per million):.
Pass � Fail m (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