HomeMy WebLinkAbout607 COWAN ST - SPECIAL INSPECTIONS - 9/28/2018Planning, Development & Transportation Services
City 01 Community Development & Neighborhood Services
ort Collins P.O.North o580lege Avenue
F P.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: _ Ke j "� J D R-L� Q.`l� Permit Number:
Address: e,o-7 Coa,�.. -,k I�%al �� Tele: q�� /2— %//
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: , 2�,E License Number:
Technician Name (print): ,Z�V) hh-� 77pss Date:
Technician Signature:
Tele:
Appliance Tested: `/O „� 1. �+� �- �, „2,�� Model #: ZG2�P�
L/ t
Appliance Replaced:
Model #:
STEP 1: Worst Case Conditions Test
SpillageBackdraft Duration (in seconds): _� Carbon Monoxide (parts per million):
Pass ('�C Fail a (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