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01!04l2017 12:33 GLOWING HEARTH&HOME �A1f�52 492 6006 P.003l005 <br /> Note:All Geothermal S�stems will now requaXe a Site Plan&Review by our$uilding Official. <br /> IS THIS G�OTHERMAL? ❑Yes 0 No <br /> H�ATYNG SYSTE1vXS <br /> Quantity: <br /> Malce: <br /> Model: <br /> Fue�: <br /> Flue Size: <br /> Input BTUs: <br /> Output BTUs: <br /> CFM: <br /> CdOLING S'S�STEMS <br /> Quantity: <br /> Make: <br /> Mode�: <br /> Tons_ <br /> H.Power <br /> �IREPLACE <br /> `�l Gas Factory Fireplace Brand Na�me: _ � a.a t� <br /> 0 'VV'ood Buming Fireplace ` ��� <br /> ❑ Wood Stove Model No.: �'�.$� �� <br /> ❑ Wood Stove with�'luc/Masoary <br /> 'VENTILA'Y"TON <br /> ❑ No. _ Kitchen Exhaust duet recireulating cfxn <br /> ❑ No. Bath�xhaust(must have duct outside) ��, <br /> ❑ No. Other�ans: Locations �;� <br /> FU��,STORAGE (Must be approved by Fire MarshaCl tf,proposing to abandon tank in place.) <br /> ❑ Installation ❑ Removal <br /> Puel 0i1: �gailons ❑ Underground ❑��,side ❑Outside <br /> T,P Gss: gations <br /> Other: <br /> A,S LI�E O X,,�:' <br /> ❑ Outdoor GrilI [] Other/�.ist What 8t Where� <br /> 2 <br />