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05/27/2015 15:32 7635354379 GOLDEN UAL�EY HTG PAGE 02/04
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<br /> i Note:AIl Geothczzzt,sl Systems will now�equaxe s S'te lan&Review by our 8uilding Official,
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<br /> �S��CS GEOTHERMA�.? ❑Yes �lo
<br /> HEA'I'11VG SXSTT�.MS
<br /> Q�ri�� �
<br /> I Make: �1�1�C
<br /> I Model: � �(�a��
<br /> �ue��
<br /> �
<br /> Flue Size:
<br /> In�ut B'I'Us� ���t r,��
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<br /> i Qutput BTUs: � ��
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<br /> I Ck'N�'
<br /> � CO��.�1VG SXSTEMS
<br /> IQuaatity_ �
<br /> �
<br /> i ��e' ��
<br /> ' Model: /� �/ �O�U
<br /> �
<br /> ' � 5i Tans: `
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<br /> � H.Power
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<br /> � F'IREPI.ACES
<br /> j ❑ Gas k'actory Fireplace Brand Name:
<br /> � ❑ Wood�urni�ng Fireplace
<br /> i ❑ Wood 5Rove h�odel No._
<br /> � (] Wood Stove with Plue/Maso�iry
<br /> I
<br /> � VENTILATI�N
<br /> I ❑ No. Kitchen Exhanst duct recirculatinb cfrn
<br /> i ❑ No. 13ath��chaust(must have duct outside) cfm
<br /> I
<br /> � ❑ No• Other Fans: Locations �frn
<br /> i �UEL S'I`ORAGE (Mus!be approved by Fire Marshall if,pro,posing to abandotr tank ln place.)
<br /> I
<br /> � ❑ �nstallat;on ❑ Re�oval
<br /> � Fuel Oil: gallons ❑ Underground ❑lnside ❑�utside
<br /> LP Gas: �_ gallons
<br /> Other:
<br /> CAS LINE ONLY
<br /> i ❑ putdoar Gnll ❑ Ottl;er/List what&Where:
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<br /> I 2
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