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sH• , s <br /> � i� { - io ,4oa-4LAS�lf. lvKs i} 8* ..,5,_ <br /> :a' .- 1r :' a v :i <br /> r HEATING SYSTEMS Q. <br /> Quantity: <br /> Make • " '?irl <br /> Model . <br /> n . • '560100 r . 5 Ili°; <br /> Fuel iv a <br /> Flue Size <br /> t -,-.''4'-'r-z <br /> } <br /> Input BTUs `�"� 1,C3bto6 - <br /> p <br /> Output BTUs 9 3 } <br /> C <br /> IY <br /> CFM: °QC . <br /> COOLING SYSTEMS <br /> Quantity:. t f <br /> make: <br /> Zt 'a <br /> . _ ., , l: ' <br /> Model: h9 l ii 11/1\0'/ . 1 g7/ p/ , <br /> Tons: <br /> H.Power <br /> FIREPLACES <br /> I:=1Gas Factory Fireplace <br /> ❑ Wood Burning Fireplace <br /> ❑ Wood Stove <br /> ❑ Wood Stove With Flue <br /> Brand Name: Model No.: <br /> VENTILATION <br /> ❑ No. t Kitchen Exhaust duct recirculating �va0`cfrn <br /> ❑ No. BathExhaust(must have duct outside) cfm <br /> LI No. Other Fans: Locations cfrn <br /> FUEL STORAGE(MUST BE APPROVED BY FIRE MARSHALL) <br /> ❑ Installation ❑ Removal <br /> Fuel Oil: gallons I:=1Underground 1:1Inside 1-_-_;1 Outside <br /> LP Gas: gallons <br /> Other: <br /> GAS LINE O <br /> ❑ Outdoor Grill ❑ Other/List What&Where: V i 2 to\ <br /> 2 <br />