Title Page

  • Client / Site

  • Title

  • Conducted on

  • Prepared by Michael J. Dominianni

  • Location
  • Cost

  • Paid by

Building Information

  • House

  • Address

Exterior Chimney Chase

    Exterior Chimney Chase
  • Chimney Name

  • Viewed From

  • Chase Material

  • Other

  • Evidence of

  • Other

  • Items attached

  • Roof Flashing

  • Obstruction Clearance

  • Extended at least 3' above roof

  • 2' higher than anything 10' around

  • Number of flues in chimney

  • Evidence of

  • Rain Cap

  • Installed

  • General Chimney Chase Comments

  • Chimney Chase Photos

Firebox/Appliance Evaluation

    Fireplace
  • Fireplace name

  • Fireplace type

  • Fuel type

  • Fireplace face

  • Other

  • Face condition

  • Other

  • Firebox

  • Firebox condition

  • Height, Width, and Depth

  • Hearth Extending at least 16" in front of and at least 8" beyond the sides

  • Damper

  • Fireplace screens

  • Fireplace doors

  • General Fireplace Comments

  • Fireplace Photos

  • Appliance
  • Appliance

  • Appliance name

  • Appliance type

  • Fuel type

  • Thimble

  • Other

  • Vent

  • General Appliance Comments

  • Appliance Photos

Flue Evaluation

    Flue Evaluation
  • Flue Name:

  • Smoke Chamber

  • Overall Smoke Chamber Condition

  • Smoke Chamber Issues

  • Flue liner

  • Overall Flue Condition

  • Inspected from

  • Liner Material

  • Shape

  • Size

  • Flue Issues

  • Other

  • General Liner Comments

  • Flue and Smoke Chamber Photos

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.