HomeMy WebLinkAbout901 DEERHURST CIR - SPECIAL INSPECTIONS - 2/18/2017Planning, Development & Transportation Services
City �1 Community Development & Neighborhood Services
281 North College Avenue
P.Box 580
Fort Collins FortrtColli s,CO80522.0580
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: (qc;(.d' 14 V, C Permit Number: / n %r•,
Address: �it9 5� ► C Tele: c?� ,-�0q
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: le. L 1 C�, M e C I'f ' License Number:
Technician Name (print): Pe rr r1 -0 Z Date:
Technician Signature:
Appliance Tested:
Appliance Replaced
Tele: �'C. Cr - 1i '? 's,. z 7 3
Model #:
,c 7t-:Ir j— c-%-4 f odel #: 4-5 t—
STEP 1: Worst Case Conditions Test
SpillageBackdraft Duration (in seconds): � Carbon Monoxide (parts per million): v
Pass 1�( Fail (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): 4 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) / Cr��lC
Owner's Signature �.���L/1Ll� Li �!; ui �� Datec:,? r
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