Chimney Verification Form
Date of Signed
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Information
*
Rows
Information
Block
Lot
Qualification Code
Permit
Work Site Address
Owner in Charge
Verifying Person
Company
Telephone Number
Check the applied one(s).
*
Rows
Satisfied
Not satisfied
Conversion from oil to gas
1
2
Conversion from gas to oil
3
4
Replacement of a gas appliance
5
6
Replacement of oil for oil
7
8
Vent with the "B" label
9
10
Vent with the "L" label
11
12
A supple lining
13
14
A power outlet
15
16
Interior of the Chimney
17
18
Exterior of the Chimney
19
20
Tile-Lined Masonry Chimney
21
22
Lined Masonry Chimney
23
24
Type/ Fuel Type/ BTU Rating
Rows
Oil/ Gas/ Other
BTU Rating
Appliance 1
Appliance 2
Appliance 3
Liner for Chimneys
Rows
Information
Manufacturer Name
Model
UL Listing
Material
What is the appliance's venting system?
*
Natural Draft
Fan assisted
Other
Signature or the conversion of oil or coal to gas
*
Signature for replacements for oil-to-oil or gas-to-gas appliances, or extra appliances
*
Signature for the appliances with a direct vent
*
Signature for no verification has been submitted
Submit
Should be Empty: