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�, <br /> � . � <br /> ��;° ; <br /> '�.,,t�� F,;r., ' ,� <br /> HEATING SYSTEMS <br /> Quantity: <br /> Make: <br /> Model: <br /> FueL• <br /> Flue Size: <br /> Input BTUs: <br /> Output BTUs: <br /> CFM: <br /> COOLING SYSTEMS <br /> Quantity: <br /> Make: <br /> Model: <br /> Tons: <br /> H.Power <br /> FIREPLACES <br /> � Gas Factory Fireplace�a� <br /> ❑ Wood Burning Fireplace <br /> ❑ Wood Stove <br /> ❑ Wood Stove With Flue <br /> Brand Name: ['�A."t' `� �'7�l� Model No.: (QUUO�C f '��I C a� <br /> VENTILATION <br /> ❑ No. Kitchen Exhaust duct recirculating cfin <br /> ❑ No. Bath E�aust(must have duct outside) cfin <br /> ❑ No. Other Fans: Locations �� <br /> FUEL STORAGE(MUST BE APPROVED BY FIRE MARSHALL) <br /> ❑ Installation ❑ Removal <br /> Fuel Oil: gallons ❑ Underground ❑Inside ❑Outside <br /> LP Gas: gallons <br /> Other: <br /> GAS LINE ONLY <br /> ❑ Outdoor Griil ❑ Other/List What&Where: <br /> 2 <br />