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Heating and Ventilation System Certificate 22-186 (E) CITY OF COLUMBIA, MISSOURI A satety inspection by a journeyman or master mechanic licensed by the City of Columbia is Fequired for rental units with any fuel fired appliances. All fuel fired appliances in the premises shall be inspected. No inspection is required for units that are all electric; the owner or operator should sign at the bottom for units that are all electric. REVISED TRIAL FORM — APRIL 2017 Rental Property Address: Unit numbers, Apt, or Rm: Inspection date: Equipment Descripti Type Location Serial # Make Mode! Type of Fuel Total BTU input ofall vented gas appliances per chimney: Sized properly? 0 Type of Chimney: masonry OCiassB other 1 Exposed masonry Type of Liner: none O metal Oflex-iner — B-vent Combustion air supply: Clyes 1 properly sized Calculations: Safety & Operating Control Tests: Pass Pass Pilovflame safeguard operating property )_—_Limit(s) operating properly a Low water cut-off operating properly (boiler) All controls operating property a Fuel piping system satisfactory Bummer lights smoothly a (Not galvanized) Connector, vent, chimney satisfactory 1_—Visual Inspection (Plenums, supplies, returns, etc. (Does not exceed length limit) Pass Does the heating system operate Yes Noa Heating unit satisfactory ly and properly? Combustion chamber/smoke bomb test Vents property without spillage Flame stays inside/doesn't roll out Carbon monoxide, in house PPM. It the heating system does not operate safely and properly, the system needs to be repaired or replaced, with the proper permits. Qo00a0a Comments: HEATING AND VENTILATION SYSTEMS CERTIFICATION This is to certiy that | have inspected the water heating, space heating and ventilation systems in the above premises and the systems are functioning properly and safely. This certificate is issued in association with obtaining a certificate of compliance. Name of licensed contractor Contractor Address Phone # Mechanic Name (printed), License # Mechanic's Signature ELECTRIC HEATING AND VENTILATION SYSTEM CERTIFICATION This is to certify that the water heating, space heating and ventilation systems at the above address are all electric. No inspection is required. One form per rental application is acceptable fo submit for all-electric units. Date. Rental Property OwneriAgent (Print) Rental Properly Owner/Agent (Signature)