HomeMy WebLinkAbout4256 GEMSTONE LN - SPECIAL INSPECTIONS - 3/7/2018City of
®rt 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
fcyay.corn
Combustion Safety Test Compliance Form
Replacement of Natural Draft Appliances in Existing Houses 7
Home Owners Name: (, �J K Permit Number: �/ � 0 �C/7
Address: Z S Tele: Z 3! %D Z 1
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: 7 License Number:
Technician Name (print): v 7�I 5Date:
Technician Signature: Tele: J�IQ i�L
Appliance Tested:
Appliance Replaced:
Model #:
STEP 1: Worst Case Conditions Test
Spillage/ B k all Duration (in seconds): Carbon Monoxide (parts per million): 7,
Pass Fail (Technician must test under Natural Conditions if "Failed')
Technici n's recommendations to cold appliance failure:
STEP 2: NaturaFConditions Test
Spill age/Back draft Duration (in seconds):
Pass Fail
(parts per million):
(Failed test requires corrections u test passes under Natural Conditions.)
STEP 3: Home Owner Signat
I certify that I am the legal ow r of the above listed property.
Owner's Name
Owner's Si
Date
In the event t at my appliance has failed a Combustion Safety "rest under worst -case
conditions I hereby acknowledge that I have received a combustion appliance safety
informati n sheet. (initial)
Further information can be obtained at www.fcgov.com/building/greenclasses.php