Exterior Masonry Chimney Evaluation Form

• Site conducted

  Select

• Conducted on

  Date

• Prepared by

• Location
  Address

• Add media

  Media

• EXTERIOR MASONRY CHIMNEY EVALUATION

  Yes

  No

  N/A

• Location of chimney? Front, Rear, Left side, Right side, Center or other

• Chimney located interior or exterior?

  Yes

  No

  N/A

• Height of chimney from roof up?

  Yes

  No

  N/A

• from ground up?

  Yes

  No

  N/A

• Is the chimney leaning or separating from the house?

  Yes

  No

  N/A

• If yes, Explain

  Yes

  No

  N/A

• Does the chimney have a crown?

  Yes

  No

  N/A

• Condition of the crown?

• Is the top of the chimney covered with a masonry cap

  Yes

  No

  N/A

• or multiflu cap

  Yes

  No

  N/A

• Type of roof? Shingle, Tile, Slate, Metal, Other

  Yes

  No

  N/A

• Style

  Yes

  No

  N/A

• Color of shingles

  Yes

  No

  N/A

• Is the roof walkable?

  Yes

  No

  N/A

• Pitch

  Yes

  No

  N/A

• Condition of the flashing?

• Condition of Cricket (If applicable)

• Chimney veneer? Brick/Stone

  Yes

  No

  N/A

• Texture

  Yes

  No

  N/A

• Color

  Yes

  No

  N/A

• Dimensions

• Block

  Yes

  No

  N/A

• Condition

• Stone

  Yes

  No

  N/A

• Condition

• Color

• Mfg

• Surface of chimney, any evidence of: Efflorescence

  Yes

  No

  N/A

• Moss

  Yes

  No

  N/A

• Rust

  Yes

  No

  N/A

• Loose Brick? Yes

  Yes

  No

  N/A

• If yes, how many?

• Location

• Spalled brick? Yes

  Yes

  No

  N/A

• If yes, how many?

• Location

• Split Brick? Yes

  Yes

  No

  N/A

• If yes, how many?

• Location

• Spider Webbing brick? Yes

  Yes

  No

  N/A

• If yes, how many?

• Location

• How many total bricks need replaced?

  Yes

  No

  N/A

• If yes, Amount?

• Does customer have any brick? Yes

  Yes

  No

  N/A

• Missing mortar joints? Yes

  Yes

  No

  N/A

• If yes, location

• Mortar Joints: Type

• Color

• Texture

• Type of Sand

• Corbels: Condition

• Number of Flues?

• Identify flue #1

• Lined or Unlined?

  Yes

  No

  N/A

• What Type of Liner: Clay:

• Stainless-Steel

• Aluminum

• Other:

• OD:

• ID:

• Does flue have any angles or Straight Run?

• If yes: Approx how far down into flue and which way does it kick?

• Does flue have a chimney cap? Yes: No: What type if yes:

• Height from smoke shelf of fireplace to top of the chimney?

• Height of the flue from thimble to the top of chimney?

• Addition comments:

• Identify flue #2

• Lined or Unlined?

  Yes

  No

  N/A

• What Type of Liner: Clay:

• Stainless Steel

• Alumi:

• OD:

• ID:

• Does flue have any angles or Straight Run?

• If yes: Approx how far down into flue and which way does it kick?

• Does flue have a chimney cap? Yes: No: What type if yes:

• Height from smoke shelf of fireplace to top of the chimney?

• Height of the flue from thimble to the top of chimney?

• Addition comments:

• Identify flue #3

• Lined or Unlined?

  Yes

  No

  N/A

• What Type of Liner: Clay:

• SS:

• Alumi:

• Other:

• OD:

• ID:

• Does flue have any angles or Straight Run?

  Yes

  No

  N/A

• If yes: Approx how far down into flue and which way does it kick?

• Does flue have a chimney cap? Yes: No: What type if yes:

• Height from smoke shelf of fireplace to top of the chimney?

• Height of the flue from thimble to the top of chimney?

• Addition comments:

• Identify flue #4

• Lined or Unlined?

  Yes

  No

  N/A

• What Type of Liner: Clay:

• SS:

• Alumi:

• Other:

• OD:

• ID:

• Does flue have any angles or Straight Run?

• If yes: Approx how far down into flue and which way does it kick?

• Does flue have a chimney cap? Yes: No: What type if yes:

• Height from smoke shelf of fireplace to top of the chimney?

• Height of the flue from thimble to the top of chimney?

• Addition comments:

• Are any of the Liners:

• Gaps

  Yes

  No

  N/A

• Too small

  Yes

  No

  N/A

• Spalling

  Yes

  No

  N/A

• Too large

  Yes

  No

  N/A

• Missing pieces

  Yes

  No

  N/A

• Cracked

  Yes

  No

  N/A

• Will liners need removed, Reason?

• Is a video scan required?

  Yes

  No

  N/A

• What vents into flue(s)? (see below, check all that applies)

• TYPE OF APPLIANCES: Gas

  Yes

  No

  N/A

• Oil

  Yes

  No

  N/A

• Fireplace

  Yes

  No

  N/A

• Boiler

  Yes

  No

  N/A

• HWT

  Yes

  No

  N/A

• Other

  Yes

  No

  N/A

• Appliance info?

• Flue #1

  Yes

  No

  N/A

• Connecting Pipe Size

• BTU’S

• Condition

• Flue #2

• Connecting Pipe Size

• BTU’S

• Condition

• Flue #3

• Connecting Pipe Size

• BTU’s

• Condition

• Flue #4

• Connecting Pipe Size

• BTU’S

• Condtion

• Are there any 2 appliances in the same flue? Yes

  Yes

  No

  N/A

• Signs of water? Yes

  Yes

  No

  N/A

• If yes, where

• If Yes, Recommend water test now. See pricing in price book

  Yes

  No

  N/A

• Customers remarks/requests:

• Needed Repairs:

PHOTOS

• Add media

  Media