Title Page
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Service Number
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Customer
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Location
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Conducted on (Date and Time)
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Prepared by (Full Name)
System Information
Fireplace
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Construction
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Please specify
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Opening size
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Fuel
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Heating appliance type
Chimney
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Construction
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Height
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Liner
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Size
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Last cleaning inspection
Inspection
Chimney
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Height
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Chimney Cap / Spark Arrestor
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Crown / Wash
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Brickwork / Mortar
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Flashing
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Flue Liner
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Moisture Resistance
Fireplace
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Smoke Chamber
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Damper
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Firebox / Grate
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Ash Container
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Spark Screen / Doors
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Tools / Gloves
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Heart Protection
Stove or Fireplace Insert
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Connector Pipe Condition
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NFPA/IRC Approved Connection and Flue
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Installation / Thimble / Clearances
Other Safety Considerations
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Fire Ext. / Smoke Detectors / CO Alarms
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Gas / Oil Furnace Flue Liner
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Fire Escape Plan
Completion
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Recommendations
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Inspector (Full Name and Signature)