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Fr�m:COUNTRYSIDE HEATING & COOLING 763 479 2518 03/31l2015 14:36 #035 P.0021003 <br /> � <br /> �'� L 2 .� . -�J Fu�,��.�„�.�, a�� �. <br /> �� � <br /> .�._-'' ..N. .,..:..... ., ..,. �...... � ���� ,.....,... �� <br /> . ............... d�<r �' ��'h��'��: �.J.Y$. h:..,�s <br /> Note: All Geothermal Systems will now require a Site Plan& Review by our Building Official. <br /> IS THIS GEOTHERMAL? ❑Yes �No <br /> HEATING SYSTEMS <br /> f <br /> Quantiry: � <br /> Make: � G� 1 ��� <br /> Model: l� � ��O ��� <br /> Fuel: • �" <br /> Flue Size: <br /> �II__�_._ <br /> Input BTUs: LSo ��� <br /> Output BTUs: �6 00� <br /> CFM: �C7 <br /> COOLING SYSTEMS <br /> Quantity: � <br /> Make: �(��-� � <br /> Model: J}� �(O�C— <br /> Tons: � T�� <br /> H.Power �• � <br /> FIREPLACES <br /> ❑ Gas Factory Fireplace Brand Name: _ <br /> ❑ Wood Burning Fireplace <br /> ❑ Wood Stove Model No.: <br /> ❑ Wood Stove with Fiue/Masonry <br /> VENTILATION <br /> ❑ No. Kitchen Exhaust duct recirculating cfm <br /> ❑ No. Bath Exhaust(myst have duct outside) cfin <br /> ❑ No. Other Fans: Locations cfm <br /> FUEL STORAGE (Must be appraved by Fire Marshol!ifproposing to abandon tank in place.) <br /> ❑ Installation ❑ Removal <br /> Fuel Oil: gallons ❑ Underground ❑lnside ❑Outside <br /> LP Gas: gallons <br /> Other: <br /> GAS LIPIE ONLY <br /> ❑ Outdoor Grill ❑ Other/List What&Where: <br /> 2 <br />