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Installation Name:_________________________________________ Installation Date:___________________
Installation Address:_________________________________________________________________________
Start-Up Contractor's Name_________________________________
Name of Technician_________________________________________________________________________
■ Appliance
(Information below can be obtained from appliance name plate)
Manufacturer:______________________________________________________________________________
Type (circle one): [
Boiler / Furnace / Other
Input MBH:_______________ Original Appliance Designed for (circle one): [
Output MBH:______________
Limits
Temperature
Pressure
LWCO
Other Limits
■ Burner
Fuel: [
Natural Gas / Propane
Combustion Head: [
F3G / F4G / F6G
Air Band Setting:____________ [
■ Chimney/Smoke Pipe
Masonry / Metal Vent / Direct Vent
Chimney Type:[
Chimney Height:_____________
Number of Elbows:____________
Thermal Safety Switch Installed [
Gas Supply Piping
Pipe Diameter:________
Gas Pressure to Burner Gas Valve While Burner is Operating ____________ Inches W.C.
■ Combustion Readings
O
_________% CO:__________ PPM
2 :
Manifold Gas Pressure:______________ (Inches W.C.)
Contractor Start-Up Form
]
Limit Model No.
(Indicate n/a if not required by the appliance manuf.)
] Model #:________________
]
Fuel Orifice Size:________ Air Shutter Setting:____________
or Blank Band Installed
Flue Pipe Size:______________
Confirm Double Acting Draft Regulator Installed: [
Yes / No
] Voltage: [
Length of Pipe from Burner to Meter:_________
CO
2 :
Model #:_______________
Serial #:_________________________
]
Baffle: [
Installed / Not Required
] Location (circle one): [
Flue Pipe Length:________________
120V / 24V
]
_________% Stack Temperature (325°F MIN.):__________°F
Draft at Breach___________________________W.C.
9
Phone:__________________________
Serial #:____________________
Oil / Natural Gas / Propane
Operation Verified
YES
/
NO
YES
/
NO
YES
/
NO
YES
/
NO
Inside / Outside
]
Yes / No
]
Number of Elbows:__________
]
/
n/a
]
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