HomeMy WebLinkAbout4625 BRENTON DR - SPECIAL INSPECTIONS - 2/8/2018Planning, Development & Transportation Services
Community Development & Neighborhood Services
City of 281 North College Avenue AdFlirt � m P.O. Box 580
AE� Fort Collins, CO 80522.0580
970.416.2740
970.224.6134-fax
fcgovxom
Combustion Safety Test Compliance Form
Replacement of Natural Draft Appliances in Existing Houses
Home Owner; lvaiaq :—mil (f�/� � Permit Number
Address:�l�7�,%�<�� 1_;2A Tele:
Licensed Contractor:
I hereby attest that I have pi: forned the following Combustion Safety Test in accordance with Fort
Collins Combustion Safety Test Guide Version 5, February 2012.
Company `1anne: Q�f�e r% � License Number:
Technician Name (print): Date:
Technician Signature: Tele: _=fi0llp0
Appliance Tested: �t0�`'.��2 el ##: 1"7 ^%
Appliance Replaced;*O t�r�
STEP Y: Worst Case Conditions Test
Spillagc/Rackdraft Duration (in seconds): —ram Carbon Monoxide (parts per million):
Pass 1/' Fail (Technician must test under Natural Conditions if "Failed')
Technician's recommendations to correct tested appliance failure:
STEP:t: Nat:ura.l. Conditions Test
Spillage/Backdraft Duration (in seconds): Carbon Monoxide (parts per million):
Pass Fail
(Failed test requires corrections until testpasses under Natural Conditions.)
STEP 3: Home Owner Signature
I certify thai I ao1 the: legal owner of the above listed property.
Owner's Pdarne (print) �(iLl,✓ H t./G'>� __
Owner's Signature Date ZZ — R— /:2
i
In the event that my appliance has failed a Combustion Safety Test under worst -case
conditions, :'acrcuy, acknov.4--dg e that I have received a combustion appliance safety
information sheer. _ rinitial)
Further information can be obtained at www.fegov.com/building/greenclasses.php