HomeMy WebLinkAbout927 SNOWY PLAIN RD - SPECIAL INSPECTIONS - 7/2/2018Planning, Development & Transportation Services
Ctty �" Community Development 281 North Co a" College Avenue
g rhood Servicesei hha
`F P.O. Box 580
cart C3lltri Fort Collins, CO80522.0580
970.416.2740
970.224.6134-fax
fcgov.com
Combustion Safety 'Pest Compliance Form
Replacement of Natural Draft Appliances in Existing Houses
Home Owners Name: rayg�j� permit Number: I �60 5 3 a
Address: 9�p Jw?ow 1, O -�r�—� Tele:
Licensed Contractor:
I hereby attest that I have performed the following Combustion Safety Test in accordance with Fort
Collins Combtisticu: Safety Test Guide Version 5, Febraarj 2012. pp
Company Name: _ �/1� License Number: 2! 62
Technician Name (print): Date: ZZm/Z
Technician Signature. Tele: QyP —S�
Appliance Tested: Model #:f,, �QD
Appliance Replaced: �� Model #:
STEP 1: Worst Case Conditions Test.
SpillageBackdraft Duration (in seconds): _114 Carbon Monoxide (parts per million):
Pass __IZ Fail (Technician roust 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
T certify that I am the legal owner of the above listed
Owner's Name
Owner's
In the event tha�iy appliance has
conditions, Thereby acknowledge thai
information sheet. (initial)
ro
Date
t'Combustion Safety Test under worst -case
have received a combustion appliance safety
Further information can be obtained at www.fcgov.com/building/greenclasses.php