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``? e4 k. - • a <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 /> zlg Gas Factory Fireplace <br /> ❑ Wood Burning Fireplace 3 ;replace S <br /> ❑ wood Stove 4 1/,C.K,I C/�M j <br /> ❑ Wood Stove With Flue•, a v" <br /> °1' l �1'� Model No.: lc 4L- CC CZ) <br /> Brand Name:�Q W/� 1 <br /> VENTILATION I IL 36• <br /> ❑ No. Kitchen Exhaust duct recirculating 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) <br /> ❑ Installation ❑ Removal <br /> Fuel Oil: gallons ❑ Underground ❑Inside ❑Outside <br /> LP Gas: gallons <br /> Other: <br /> GAS LINE ONLY <br /> ❑ Outdoor Grill El Other/List What&Where: <br /> 2 <br />