Chimney Inspection Form
Customer Information
Customer Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Inspection Date
-
Month
-
Day
Year
Date
Condition Report
Chimney
Rows
Satisfactory
Unsatisfactory
Not Applicable
Height
1
2
3
Chimney Cap
4
5
6
Crown/Cash
7
8
9
Brickwork/Mortar
10
11
12
Flashing
13
14
15
Flue Liner
16
17
18
Moisture Resistance
19
20
21
Fireplace
Rows
Satisfactory
Unsatisfactory
Not Applicable
Smoke Chamber
22
23
24
Smoke Shelf
25
26
27
Damper
28
29
30
Lintel
31
32
33
Firebox/Grate
34
35
36
Firebrick
37
38
39
Ash Container
40
41
42
Spark Screen
43
44
45
Tools/Gloves
46
47
48
Hearth Protection
49
50
51
Wood Stove or Fireplace Insert
Rows
Satisfactory
Unsatisfactory
Not Applicable
Stovepipe Condition
52
53
54
Installation/Thimbles/Clearances
55
56
57
Other Safety Considerations
Rows
Satisfactory
Unsatisfactory
Not Applicable
Fire Ext./Smoke Detectors
58
59
60
Gas/Oil Furnace Flue Liner
61
62
63
Fire Escape Plan
64
65
66
Additional Comments
Customer Signature
Date
-
Month
-
Day
Year
Date
Patriot Chimney Signature
Date
-
Month
-
Day
Year
Date
Submit
Should be Empty: