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Manufacturer: Serial Number: Model: Flue Collar Size:
Installation manual available: � No � Yes
Installed by: Date: � Unknown Approx age:
Installed in: � Residence � Mobile Home � Combustible Alcove � Garage � Other:
Appliance location: � Basement � Main Floor � Other:
Connected to: � Masonry chimney � With s/s liner � F-B chimney � Other:
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WOODSTOVE AND FLUE PIPE
Inspection Results: Indicate inspection results for each component. Code Compliance includes proper use of listedcomponents. N/A = Not Applicable UTI = Unable To Inspect. An inspection can be expected to include some componentsmarked UTI.
Venting system that is listed and connected to this fireplace:
� ULC S610FB � ULC S629FB Model: Manufacturer:
� Masonry � Masonry with stainless steel liner � Other:
System installed by: Date: � Unknown Approx age:
Appliance location: � Basement � Main floor � Other (specify):
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FACTORY BUILT FIREPLACE
Inspection Results: Indicate inspection results for each component. Code Compliance includes proper use of listedcomponents. N/A = Not Applicable UTI = Unable To Inspect. An inspection can be expected to include some componentsmarked UTI.