Chimney Inspection

• Customer

• Email

• Phone Number

• Location
  Address

• Conducted on (Date and Time)

  Date

• Prepared by (Full Name)

System Information

Fireplace

• Construction

  Factory-built

  Masonry

  Modular

  Other

• Please specify

• Opening size

• Fuel

  Wood

  Gas

  Coal

  OIl

• Heating appliance type

  Insert

  Freestanding

  Furnace

  N/A

Chimney

• Construction

  Factory-built

  Masonry

  Modular

  Other

• Height

• Liner

  Flue tile

  Stainless

  Cast

  Unlined

  Other

• Size

• Last cleaning inspection

  Date

Inspection

Chimney

• Height

  Satisfactory

  Unsatisfactory

  N/A

• Chimney Cap / Spark Arrestor

  Satisfactory

  Unsatisfactory

  N/A

• Crown / Wash

  Satisfactory

  Unsatisfactory

  N/A

• Brickwork / Mortar

  Satisfactory

  Unsatisfactory

  N/A

• Flashing

  Satisfactory

  Unsatisfactory

  N/A

• Flue Liner

  Satisfactory

  Unsatisfactory

  N/A

• Moisture Resistance

  Satisfactory

  Unsatisfactory

  N/A

Fireplace

• Smoke Chamber

  Satisfactory

  Unsatisfactory

  N/A

• Damper

  Satisfactory

  Unsatisfactory

  N/A

• Firebox / Grate

  Satisfactory

  Unsatisfactory

  N/A

• Ash Container

  Satisfactory

  Unsatisfactory

  N/A

• Spark Screen / Doors

  Satisfactory

  Unsatisfactory

  N/A

• Tools / Gloves

  Satisfactory

  Unsatisfactory

  N/A

• Hearth Protection

  Satisfactory

  Unsatisfactory

  N/A

Stove or Fireplace Insert

• Connector Pipe Condition

  Satisfactory

  Unsatisfactory

  N/A

• NFPA/IRC Approved Connection and Flue

  Satisfactory

  Unsatisfactory

  N/A

• Installation / Thimble / Clearances

  Satisfactory

  Unsatisfactory

  N/A

Other Safety Considerations

• Fire Ext. / Smoke Detectors / CO Alarms

  Satisfactory

  Unsatisfactory

  N/A

• Gas / Oil Furnace Flue Liner

  Satisfactory

  Unsatisfactory

  N/A

• Fire Escape Plan

  Satisfactory

  Unsatisfactory

  N/A

Completion

• Recommendations

• Inspector (Full Name and Signature)

  Sign