HomeMy WebLinkAbout6227 CLYMER CIR - SPECIAL INSPECTIONS - 12/27/2018City of
Flirt Collins
Planning, Development & Transportation Services
Community Development & Neighborhood Services
281 North College Avenue
P.O. 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 ��qq
Home Owners Name: /Ua �� d /%� �«i 1 Permit Number: V -
Address: (6u 7 C/ I ✓ Ci r— Tele: 1ff l ✓ 70
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: License Number:
' �i J� Date:
Technician Name (print): 1�P✓I"� �ic
Technician Signature: �� Tele: q16 njL-1311
Appliance Tested: Gt ojf �- v,*y - Model #: PC 50 160
Appliance Replaced:
Model
STEP 1: Worst Case Conditions Test
Spillage/Backdraft Duration (in seconds): Carbon Monoxide (parts per million):
Pass A� Fail (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