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Frem:COUNTRYSIDE HEATING & COOLING 763 479 2518 10/25/2013 09;16 #837 P.002/003 <br /> �'�}� � <br /> e4�^.b a BJ.d' q. .�� ��:�:�k _ <br /> Note:All Geothennal Systems will now require a Site Plan&Review by our Building O�cial. <br /> IS THIS GEOTHERMAL? ❑Yes �No <br /> HEATING SYSTEMS <br /> Quantity: �.—'06+'1� <br /> Make: S CG(M�C �►lil <br /> ModeL• _`� <br /> Fuel: �_� ^ � <br /> Flue Size: ��� �L/4-. <br /> Input BTUs: Q _ <br /> Output BTUs: 4`5 �i�i��` �___ <br /> CFM: N � <br /> COOLII�IG SYSTEMS <br /> Quantity: __ _ <br /> Make: <br /> Model: <br /> Tons: <br /> H.Power <br /> FIREPLACES <br /> ❑ Gas Factory Fireplace Brand Name: <br /> ❑ Wood Burning Fireplace <br /> ❑ Wood Stove Model No.: <br /> ❑ Wood Stove with Flue/Masonry <br /> VENTll.ATION <br /> ❑ No. Kitchen Exhaust duct recirculating cfm <br /> ❑ No. $ath E�chaust(must have duct outside) cfm <br /> ❑ No. Other Fans: Lacations cfm <br /> FUE�.STQRAGE (Must be approved by Fire Marshal/if proposing to abandon tank in place.) <br /> ❑ Installation ❑ Removal <br /> Fuel Oil: gallons ❑ Underground ❑Inside ❑Outside <br /> LP Gas: gallons <br /> Other: <br /> GAS LINE ONLY <br /> ❑ Outdooz Grill ❑ Other/List Whai&Where: <br /> 2 <br />