HomeMy WebLinkAbout629 S HOWES ST - SPECIAL INSPECTIONS - 11/28/2018Planning, Development & Transportation Services
City
od Community Development & Neighborhood Services
1 281 North College Avenue
Flirt Collins P.O Box580
rort Collins, CO 80522.0560
970.416.2740
970.224.6134-fax
fcgov.com
Combustion Safety Test Compliance Form
Replacement of Natural Draft Appliances in Existing Houses
Flome Owners Name: 66It fy- Permit Number:
Address: Q'i, Fi0*_!'5 Tele:
Licensed Contractor:
t 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: Fort Collins Heating and Air License Number: H1309
Technician Name (print): L$St_ t Date: i �2�6II
Technician Signature: ;'� ��/%% Tele: `� 9ti—q55 7—
Appliance Tested: L+1a�gakr-Model #:
Appliance Replaced: ( LA.rta&cti Model q Ia1ANZee2Uvl-7A
STEP 1: Worst Case Conditions Test
Spillage/Rarkdraft Duration (in seconds): Carbon Monoxide (parts per million):'
Pass Pail (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 ant the le -al 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.cont/building/greenclasses.php