HomeMy WebLinkAbout4425 VIEWPOINT CT - SPECIAL INSPECTIONS - 11/14/2018Planning, Development & Transportation Services
N'p� Community Development & Neighborhood Services
11�.00ff4C c 281 North College Avenue
P.O. Box 5130
F6 t C®Ulm n.s Fort Collins, CO 80522.0580
970.416.2740
970.224.6134-fax
Icgov.com
Combustion Safety Test Compliance Form
Replacement of Natural Draft Appliances in Existing Houses
Home Owners Name:`` tY oe Permit Number:
Address: —wit —as v14A\ -Lkob--)
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: M iA t,�t License Number:
Technician Name (print): Date:
Technician Signature: Tele: q, j-Lm;a-�
Appliance Tested: Z✓k1t Model #:
Appliance Replaced: 6V&d14�i Model #:
STEP 1: Worst Case Conditions Test
SpillageBackdraft Duration (in seconds): Carbon Monoxide (parts per million): -42ZQ�
Pass 0� Fail (Technician must test under Natural Conditions if "Failed'9
Technician's recommendations to correct tested appliance failure:
STEP 2: Natural Conditions Test
SpillageBackdraft Duration (in seconds): -"Carbon Monoxide (parts per million): 40?
Pass oC 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)
Owner's Signature Date
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/buiIdingigreenclasses.php