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)