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
- Roof
- Ladder at eave
- Ground with binoculars
-
Chase Material
- Brick
- Stone
- Metal
- Framed
- Blocks
- Stucco
- Vinyl Covered
- Other
- Masonry
-
Other
-
Evidence of
- Cracks
- Cracked Crown
- Loose Mortar
- Holes in Metal
- Rust
- Flaking
- Deterioration
- Recommend installing cricket
- Efflorescence
- Other
- Nothing to note
-
Other
-
Items attached
-
Roof Flashing
- Satisfactory
- Repair
- Unsatisfactory
- Repaired. Routine maintenance might be required.
- Not Visible
-
Obstruction Clearance
-
Extended at least 3' above roof
-
2' higher than anything 10' around
-
Number of flues in chimney
-
Evidence of
- Flue not visible from exterior
- Scaling
- Cracks
- Creosote
- Nothing to note
- Other
-
Rain Cap
-
Installed
- Yes
- No, recommended
- Damaged
- Replace
-
General Chimney Chase Comments
-
Chimney Chase Photos
Firebox/Appliance Evaluation
- Fireplace
-
Fireplace name
-
Fireplace type
-
Fuel type
- Gas
- Wood
- Gas Assisted Wood
- Oil
- Propane
- Coal
-
Fireplace face
- Brick
- Stone
- Marble
- Tile
- None
- Other
-
Other
-
Face condition
- Smoke stained
- Loose
- Cracked
- Gaps between face & firebox
- Other
- None
- Satisfactory
-
Other
-
Firebox
-
Firebox condition
- Satisfactory
- Gaps between bricks
- Deterioration
- Gaps between face & firebox
- Loose bricks
- Rust
- Moisture stains
- Missing ash dump cover
-
Height, Width, and Depth
- Acceptable
- Too short
- Too tall
- Too shallow
-
Hearth Extending at least 16" in front of and at least 8" beyond the sides
- Acceptable
- Too short
- Damaged
- Gaps
-
Damper
- Operates
- Does not operate
- Broken
- Rusted
- Missing
- Other
-
Fireplace screens
- Satisfactory
- Unsatisfactory
- Loose, secure
- Broken
- None, recommended
- None
-
Fireplace doors
- Satisfactory
- Unsatisfactory
- Loose, secure
- Broken
- None, recommended
- None
-
General Fireplace Comments
-
Fireplace Photos
Appliance
-
Appliance
-
Appliance name
-
Appliance type
-
Fuel type
- Gas
- Wood
- Gas Assisted Wood
- Oil
- Propane
- Coal
-
Thimble
- Satisfactory
- Unsatisfactory
- Loose
- Rusted
- Missing mortar
- None
- Other
-
Other
-
Vent
- Satisfactory
- Unsatisfactory
- Improper pitch
- Rusted
- Loose
- Improper sizing
- Improper vent setup
- Orphaned water heater
-
General Appliance Comments
-
Appliance Photos
Flue Evaluation
- Flue Evaluation
-
Flue Name:
-
Smoke Chamber
-
Overall Smoke Chamber Condition
-
Smoke Chamber Issues
- Cracked
- Deterioration
- Obstructed
- Defective
- Missing Section
- Offset
- Broken
- Moisture
- Heavy Creosote
- Missing Flue Cement
- Spalling
- Undersized
- Oversized
- None
- N/A
- Other
-
Flue liner
-
Overall Flue Condition
- Satisfactory
- Satisfactory with concerns
- Concerns
- Unsatisfactory
-
Inspected from
-
Liner Material
- Clay Liners
- Stainless
- Cast In Place
- Resurfaced Liner
- Metal
- None
-
Shape
-
Size
-
Flue Issues
- Cracked
- Deterioration
- Obstructed
- Defective
- Missing Section
- Offset
- Broken
- Moisture
- Heavy Creosote
- Missing Flue Cement
- Spalling
- Undersized
- Oversized
- None
- N/A
- Other
-
Other
-
General Liner Comments
-
Flue and Smoke Chamber Photos
