HomeMy WebLinkAbout418 S WASHINGTON AVE - SPECIAL INSPECTIONS - 2/2/2018161 J?J%_Zola id AMAMFFOgT TO: 19702246134 FROI�g4}SAJ07234 T-866 F UPIMP: F-9221
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Planning, Development & Transportation Services
Community Development & Neighborhood $erAces
City,
of 281 North college Avenue
P.O. Box 590
F&tColhns Fort Collins, CO 80522 05BO
$70.416.2740
970 224 6134• fax
fcgov cam
Combustion Safety Test Compliance Form
Replacement of Natural Draft Appliances in Existing Houses
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: Fort Collins Heating and Air Licens Number: H1309
Technician Name (print): /
/�t �,-1 k Date: /
Technician Signature: Tele:
Appliance Tested: A / Imo_ el` lam- e-r` Model #:
Appliance Replaced:Model #:
STEP 1: Worst Case Conditions Test
Spillage/Backdraft Duration (in seconds): A O Carbon Monoxide (parts per million):
Pass —LZ" 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):
Pass K Fail
Carbon Monoxide (parts per million):
(Failed test requires corrections until test passes under Natural Conditions.)
STEP 3: Home Owner Signature
I certify that I am the legal o r of the above Ii I rr rty.
Owner's Name (print) ft �t
Owner's Signature Date 18
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.eom/building/greenclasses.php