HomeMy WebLinkAbout908 PINNACLE PL - SPECIAL INSPECTIONS - 11/3/2016/9/2016 10:03 PST TO:19702246134 FROM:7194807234 Page: 2
Planning, Development & Transportation Services
CltOf Community Development & Neighborhood services
Y 281 North College Avenue
P.O. Box 580
Fort Collins Fort Collins, CO 80522.0580
970.416.2740
970.224.8134-fax
fcgov.com
Combustion Safety Test Compliance Form
Replacement of Natural Draft Appliances in Existing Houses
Home Owners Name: 1" li/I,j�C Wu w Permit Number:
Address: q9 Finnac i2 I" y�, Tele:
Licensed Contractor:
hereby attest that 1 have performed the following Combustion Safety Test in accordance with Fort
Collins Combustion
Safety Test Guide Version 5, February 2012.
Company Name: r s'tr! // License Number:
Technician Name (print): Date:
Technician Signature: _
Appliance Tested: Ivr?
Appliance Replaced:
Tele:
STEP 1: Worst Case Conditions Test (�
Spillage/Backdraft Duration (in seconds) Carbon Monoxide (parts per million): "1 tZ�
Pass X 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
1 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 1 have received a combustion appliance safety
information sheet. (initial)
Further information can be obtained at www.fcgov.com/building/greenclasses.php