Title Page

  • Service Number

  • Customer

  • Location
  • Conducted on (Date and Time)

  • Prepared by (Full Name)

System Information

Fireplace

  • Construction

  • Please specify

  • Opening size

  • Fuel

  • Heating appliance type

Chimney

  • Construction

  • Height

  • Liner

  • Size

  • Last cleaning inspection

Inspection

Chimney

  • Height

  • Chimney Cap / Spark Arrestor

  • Crown / Wash

  • Brickwork / Mortar

  • Flashing

  • Flue Liner

  • Moisture Resistance

Fireplace

  • Smoke Chamber

  • Damper

  • Firebox / Grate

  • Ash Container

  • Spark Screen / Doors

  • Tools / Gloves

  • Heart Protection

Stove or Fireplace Insert

  • Connector Pipe Condition

  • NFPA/IRC Approved Connection and Flue

  • Installation / Thimble / Clearances

Other Safety Considerations

  • Fire Ext. / Smoke Detectors / CO Alarms

  • Gas / Oil Furnace Flue Liner

  • Fire Escape Plan

Completion

  • Recommendations

  • Inspector (Full Name and Signature)

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. You should independently determine whether the template is suitable for your circumstances.