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WoodlynneGreen Risk

ClosedBuilding & Construction

Chimney Verification

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Executive Summary

This document outlines the Chimney Verification requirements for the Borough of Woodlynne, specifically relating to the replacement of fuel-fired equipment. It details the necessary checks and verifications required for various types of fuel conversions and appliance replacements, including confirming the chimney's condition, lining, and sizing appropriateness. The form requires signatures from verifying individuals and outlines inspection procedures based on whether verification is submitted or not. This form is required with permit applications for minor and emergency work and must be presented to the code official prior to final inspection for all other work.

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Document Text

--- Document: Chimney Verification Document ---
US
NEW JERSEY
UNIFORM CONSTRUCTION
CODE
BLOCK
CHIMNEY VERIFICATION FOR
REPLACEMENT OF FUEL-FIRED EQUIPMENT
LOT
QUALIFICATION CODE
PERMIT #
WORK SITE ADDRESS
Owner in Fee.
Verifying Individual.
Address
Tel: (
)
Street
Check the Appropriate Box(es):
Type of Replacement:
Company
City
Fax: (
Existing Vent/Chimney: Size
State
Zip Code
[]
Oil to Gas Conversion
[]
"B" Label Vent
]
[]
Gas to Oil Conversion
[
"L" Label Vent
]
Chimney-Interior
Chimney-Exterior
[ ]
Gas Appliance Replacement
[
Flexible Liner
Masonry Chimney-Tile Lined
[]
Oil to Oil Replacement
[] Power Vent/Exhauster
[]
Other
]
Masonry Chimney-Unlined
Other
Type
Fuel Type
BTU Rating (input/hour)
Appliance 1:
Oil/Gas/Other:
Appliance 2:
Oil/Gas/Other:
Appliance 3:
Oil/Gas/Other:
CHIMNEY LINER
If a chimney liner is being installed, all documentation on the liner must accompany the Permit application.
Manufacturer:
Model:
UL Listing:
Material of Liner: Stainless Steel
Aluminum
Size of Appliance Vent:
Size of Liner:
Height of Chimney:
Length of Connector:
Vent Connector Rise:
How does the appliance vent?
[ ] Natural Draft [] Fan-assisted
[ ] Other:.
PLEASE SIGN ONE OF THE FOLLOWING VERIFICATION STATEMENTS
For Oil or Coal to Gas Conversions:
I have verified that the chimney/vent is in good repair and clear of obstruction and is substantially clean of residue
from its previous use serving an oil or coal appliance. I have verified that the chimney/vent is appropriately lined and
sized for the appliance(s) being installed.
Signature
Oil to Oil or Gas to Gas Replacements or New/Additional Appliances:
Date
I have verified that the existing chimney/vent is in good repair and clear of obstruction. I have verified that the existing
chimney/vent is appropriately lined and sized for the appliance(s) being installed and/or remaining.
Direct Vent Appliance:
Signature
Date
I hereby verify that the appliance(s) being installed is a direct vent appliance. I further verify that the existing chimney/
vent is appropriately lined and sized for any remaining appliances.
Verification Not Submitted:
Signature
Date
I choose not to submit verification. I understand that I will be required to be present for the inspection to remove and
reinstall the chimney vent connector.
Signature
Date
FOR MINOR AND EMERGENCY WORK, THIS FORM MUST BE PROVIDED WITH YOUR PERMIT APPLICA-
TION. FOR ALL OTHER WORK, THIS FORM MUST BE PRESENTED TO THE CODE OFFICIAL PRIOR TO FINAL
INSPECTION.
All applicable information requested on this form must be supplied.
This form may not be submitted by a homeowner in lieu of the required inspection.
U.C.C. F370 (rev. 01/12)