Viessmann Commercial Project Sign-Off Forms Set Page 3
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83. Equipment Sign-off Form
Project Name:
___________
Altitude*: ______________ ft / m
City: ____________________
State: ________
*required for installations above 2,000 ft/610m
Gas Supply Pressure: ______________ “w.c.
psig
or
Note: If gas supply is below 7”w.c. at jobsite, confirm minimum working gas pressure available
Combustion air: The burner(s) will require a ducted combustion air intake.
Y
Burner / Gas Train / Control Installation:
Burner
Burner
Burner
Gas Train
3
Gas Train Mount
Boiler Model
(left/right)
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2
Model
Fuel
Voltage
Approval
Boiler 1
Boiler 2
Boiler 3
Boiler 4
1
Burner Fuel:
Specify NG, LP, Oil, Combi NG/Oil.
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Burner Voltage:
Important: 120/1/60 always required in mechanical room for controls.
Weishaupt: WG20, WL20, WG30, WL30, WGL30, WG40, WL40 only available in 120/1/60. G7, L7 & G10/4: Only
available in 208-240/3/60, 460/3/60 & 575/3/60. All other available in all voltages.
Riello: F15, G750/900, RL28, RS28, RLS28, and RS45 only available in 120/1/60.
RL,RS,RLS 38 available in all voltages. All other Riello only available in 208-230/3/60, 460/3/60,
575/3/60.
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Gas Train Approvals, Mount and valve design
Weishaupt: The Weishaupt gas train is sold assembled and prewired; please specify left-hand side or right-hand
side (when facing boiler combustion chamber door). Available gas train approval(s) include: CSA, UL,
IRI or FM.
Important: WG20, WG30, WG40 Linkage-less burners right hand gas train only.
y
Dungs ventless (optional)
y
US ONLY
Low / high gas pressure switches: Antunes ( Standard)
Riello: The Riello gas train is sold partially assembled. Available gas train approval: UL is standard. FM and IRI
available upon special request. Contact your Viessmann representative if FM or IRI is required.
BMS:
Is Building Management System (BMS) Integration required? Yes
No
Yes
If Yes: with Gateway LON
BACNet
0 – 10V signal
Other
___________________y
LTP:
Voltage of Return Low Temperature Protection (LTP) pump:
___ ______ ______ ______
(30% LTP (Shunt pump) or 100% LTP (Return mixing valve). Only applicable to Vitorond 200 VD2 boilers.)
Pumps:
(Please list all other pumps supplied by Viessmann and their required voltages below)
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1
Service
Model Number
Voltage
Service
Model Number
Voltage
Pump 1
Pump 4
Pump 2
Pump 5
Pump 3
Pump 6
1
Examples: Domestic hot water, boiler supply, heating loop, ahu, heat exchanger etc.
_________ psi
System operating pressure:
Estimated delivery time of Material: _________________________
Signature:
Date:
Name (print):
Upon completion, please fax completed Cover Page together with completed Forms (some or all) to:
- Viessmann Canada:
(519) 885-1134
(for all provinces except BC)
- Viessmann BC:
(604) 533-9439
(for west coast Customers)
- Viessmann USA:
(401) 732-0590
(for US Customers)
Commercial Project Sign off Form
12/2010
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