Transcript
PERSONAL LINES PROPERTY SOLID FUEL HEATING QUESTIONNAIRE CLEAR PHOTOGRAPHS & QUESTIONNAIRE REQUIRED FOR EACH INSTALLATION (STOVES AND CHIMNEYS) Date:
Broker Name:
Insured Name:
Broker Number:
Policy Number:
Inspected By:
Dwelling Location:
Telephone No.:
HEATING UNIT Building appliance is installed in:
Dwelling
Garage
If in Dwelling, where?
Main Floor
Workshop
Other
Porch
Other
Basement
Manufacturer
Appliance Type
Model
Woodstove, Airtight
Wood Furnace
Age
Woodstove, Not Airtight
Wood Furnace, Add On
Fireplace Insert
Fireplace, Zero Clearance
Is the Heating Unit:
Primary
Auxiliary
Quantity of Fuel Used
Other (Specify)
Is the Unit Certified? If Yes, by:
Yes
No
Approved for Mobile Homes?
Yes
No
Canadian Standards Association (CSA)
Underwriters’ Laboratories of Canada (ULC)
Warnock-Hersey Prof. Service Ltd.
Other (Specify)
CHIMNEY Type
Masonry
Concrete Block
Brick
Built from Ground
Factory Built Double Walled Metal Chimney
Bracket
Other (Specify)
Manufacturer Certified for Wood Burning Appliances bearing the ULC-S629M Label? Labeled
Yes
No
Canadian Standards Association (CSA)
Underwriters’ Laboratories of Canada (ULC)
Warnock-Hersey Prof. Service Ltd.
Other (Specify)
If No label, explain Chimney Lining:
Clay Tile Lining
Factory Stainless Steel
Other (Specify)
Age and General Condition Chimney is installed:
Inside Building
Outside Building
Does unit share a chimney flue with any other appliance?
Yes
No
If Yes, explain.
How often is chimney cleaned per heating season?
Date last cleaned
Distance from Chimney to Combustibles
inches
INSTALLATION Was the unit installed by a Heating Contractor?
Yes
No
If No, complete below
Firm or Individual Was the chimney installed by a Heating Contractor or Masonry Contractor?
Yes
No If No, complete below
Firm or Individual Has the installation, including the chimney, been inspected by someone who it WETT certified? Have any modifications been made?
Yes
Yes
No
No If Yes, explain
Does stove pipe pass through a concealed space? (e.g. Closet, Attic, Floor, Wall)
Yes
Are ashes from appliance disposed of in a non-combustible container?
No If No, explain
Yes
No
continued over 5032-042011
Indicate Approved Clearances (see label or installation manual) Sides
inches
Front Side
inches
Back Side
inches
Top Side
inches
inches
Front
inches
Corner
inches
Back
inches
Floor Protection: Sides
Note: This section is for the manufacturer’s approved clearances as indicated on the label or brochure. The “actual” clearances are to be shown on the diagram below. COMPLETE ALL MEASUREMENTS AS PER APPLICABLE INSTALLATION ON THE DIAGRAM BELOW ALL DISTANCES ON DIAGRAMS ARE TO BE MEASUREMENTS TAKEN FROM THE PARTICULAR INSTALLATION Describe construction of ceiling
Distance from stovepipe to
Distance from top of stove to ceiling inches
ceiling
inches
wall
inches
Distance from stove to nearest
Is there a thimble/chimney connector where stovepipe passes through wall or ceiling? Yes No
side wall
Describe construction of back
Describe construction of side wall inches
Construction of Floor
wall Total length of stovepipe inches
Is there a non-combustible floor pad? Yes No
Construction of stovepipe
Type of Floor Protection
Galvanized Single Wall
Distance from end of floor protection to stove:
Black Steel Double-lines
Distance from stove to back wall inches
Front
inches
Side
inches
Back
inches
Distance from bottom of stove to floor protection: inches Distance from stove to furniture, fuel or other combustible material inches
If Shielded Installation, please answer the following: Type and thickness of shield Construction of spacers Distance from wall to shield inches
Distance from top of stove to top of shield inches
Distance from back of stove to back of wall behind stove inches
Distance from side of stove to wall behind shield inches
Distance from heat shield to floor
Distance from front of stove to front of shield inches
inches
COMMENTS
Completed By
Date
5032-042011
