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From:COUNTRYSIDE HEATING & COOLING 763 479 2518 10/25/2013 10:27 #838 P.002/003 <br /> , • <br /> ��a ��� � k �,��� y... ,. ..Y. . . . <br /> �r,. F,�,,, _ � �� <br /> Note:All Geothermal Systems will now require a Site Plan&Review by our Building O�cial. <br /> IS THIS GEOTHERMAL? ❑Yes ❑No <br /> fIEATING SYSTEMS <br /> Quantity: ________ _� _ <br /> Make: <br /> Model: <br /> Fuel: <br /> Flue Size: <br /> Input BNs: __, ___ � <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 Brand Name: ���w <br /> ❑ Wood Buming Fireplace �u �..v��� �n� <br /> ❑ Wood Stove Modei No.: �vi�ti � w- <br /> ❑ Wood Stove with Flue/Masonry <br /> VENTILATION <br /> ❑ No. Kitchen Exhaust duct recircuiating cfm <br /> ❑ No. Bath Exhaust(must have duct outside) cfm <br /> ❑ No. Other Fans: Locations cfm <br /> FUEL STORAGE (Must be approved by Fire Marshall if proposing to abando�r tank in place.) <br /> ❑ Installation ❑ Removal <br /> Fuel Oil: gallons ❑ Underground ❑Inside ❑Outside <br /> LP Gas: gallons <br /> Other: <br /> GAS LINE ONLY <br /> ❑ Outdoor Gritl ❑ Other/List What&Where: <br /> 2 <br />