X-593 SOLID FUEL HEATING QUESTIONNAIRE

Transcription

1 X-593 SOLID FUEL HEATING QUESTIONNAIRE CLEAR PHOTOGRAPHS & QUESTIONNAIRE REQUIRED FOR EACH INSTALLATION (UNITS & VENTS) NAME ADDRESS PHONE NO POLICY NO BROKER INSPECTED BY DATE GENERAL INSTALLATION QUESTIONS Are ashes / clinker from appliance disposed of in a non-combustible container? Yes No If no, explain: Was unit installed by a certified heating contractor? Yes No Firm or individual: Was chimney installed by a certified heating contractor? Yes No Firm or individual: Does the furnace share a chimney flue with any other appliance? Yes No If yes, explain what other appliance: Which appliance has the lowest connection? Does stove pipe pass through a concealed space? (eg Closet, Attic, Floor, Wall) Yes No Quantity of fuel used Distance from unit to furniture, fuel, walls How often is chimney cleaned per heating season? Date last Cleaned Have any modifications been made to unit or chimney? Yes No If yes, explain CHIMNEY INSPECTION MASONRY Shell Material Chimney Liner Type Built from: Ground Bracket Liner size Height above crown Foundation Type Chimney Crown Type Chimney Breech or Thimble Material Type Wall Pass-through Type Flashing Type Clean-out Door Yes No Location Clearances to Combustibles Clearances to Combustibles Required Actual Required Actual Vertical 36 Inside 2 Horizontal 10 Outside ½ Chimneys must extend 24 above obstacles within a horizontal distance of 10 X-593 wwwmymutualinsuranceca Page 1 of 5

2 FACTORY-BUILT METAL Roof Brace (required if chimney is over 60 above roof) Type Model Required Yes No Total Height Flue Size Inside Outside Certified? Yes No Rain Cap Must be certified to ULC-S629M (650 degrees C) Flashing Chimney Support Clearances above Roof Adequate Base Support Yes No Required Actual Adequate Ceiling Support Yes No Vertical 36 Use of factory components Yes No Horizontal 10 Chimneys must extend 24 above obstacles within a horizontal distance of 10 Intermediate Support (wall support bands) Adequate? Yes No Clearance from Combustibles Use of factory components Yes No Required Actual 2 SPACE HEATERS / COOK STOVES Indicate Actual Clearances on Diagram (see over) Building Appliance is installed in: Dwelling Garage Workshop Other If in Dwelling, where? Main Floor Basement Porch Other Model Appliance Type Is appliance: Certified? Yes No Approved for Mobile Home? Yes No If yes, Canadian Standards Underwriters Laboratories of Canada Warnock-Hersey Ltd (CANADA) Omni-Test Laboratories, Inc Indicate approved clearances (see label or installation manual) Top: Corner: Floor Protection Required: Yes No NOTE: This section is for the sole use of the s approved clearances as indicated on the label or brochure Actual clearances are to be shown on the diagram below X-593 wwwmymutualinsuranceca Page 2 of 5

3 ALL DISTANCES ON DIAGRAMS ARE TO BE MEASUREMENTS TAKEN FROM THE PARTICULAR INSTALLATION Distance from top of stove to ceiling Describe construction of nearest side wall Distance from stove to nearest side wall Construction of Floor Type of floor protection protection to stove: Front Side Back NON SHIELDED INSTALLATION or ceiling Yes No Describe construction of ceiling Describe construction of back wall Distance from stove to back wall Describe construction of ceiling SHIELDED INSTALLATION Distance from the top of stove to ceiling Describe construction of side wall Type and thickness of shield Distance from wall to shield Distance from front of stove to front of shield Distance from side of stove to wall behind shield Construction of floor Type of floor protection protection to stove Front, Side Back or ceiling? Yes No Describe construction of back wall Distance from top of stove to top of shield Distance from back of stove to back of wall behind shield Construction of spacers Distance from heat shield to floor Comments: Completed by Date X-593 wwwmymutualinsuranceca Page 3 of 5

4 ALL DISTANCES ON DIAGRAMS ARE TO BE MEASUREMENTS TAKEN FROM THE PARTICULAR INSTALLATION Distance from top of stove to ceiling Describe construction of nearest side wall Distance from closest corner of stove to left side wall Construction of Floor Type of floor protection protection to stove: Front Side Back CORNER INSTALLATION Non-Shielded or ceiling Yes No Describe construction of ceiling Describe construction of back wall Distance from closest corner of stove to right side wall Describe construction of ceiling Distance from the top of stove to ceiling Describe construction of side wall Type and thickness of shield Distance from wall to shield Distance from front of stove to front of shield Distance from side of stove to wall behind shield Construction of floor Type of floor protection protection to stove Front, Side Back Comments: CORNER INSTALLATION Shielded or ceiling? Yes No Describe construction of back wall Distance from top of stove to top of shield Distance from closest corner of stove to back of wall behind shield Construction of spacers Distance from heat shield to floor Completed by Date X-593 wwwmymutualinsuranceca Page 4 of 5

5 CENTRAL HEATING FURNACES / ADD-ON WOOD BURNING APPLIANCE: Building Appliance is installed in: Dwelling Garage Workshop Other If in Dwelling, where? Main Floor Basement Porch Other Model Is appliance: Certified? Yes No Appliance Type If yes, Canadian Standards Underwriters Laboratories of Canada Warnock-Hersey Ltd (CANADA) Omni-Test Laboratories, Inc If appliance is an Add-On : Is it approved for use with existing furnace? Yes No Is the furnace installed downstream between hot air outlet of original furnace and it s distribution ducts? Yes No Indicate approved clearances (see label or installation manual) Above Hot Air Plenum: Above First 6 of Hot Air Plenum: Floor Protection Required: Yes No Fueling Door End: NOTE: This section is for the sole use of the s approved clearances as indicated on the label or installation instructions Actual clearances are to be shown on the diagram below Indicate Actual Clearances on the Diagram Below: Describe return air ducting Describe sidewall construction (nearest) Left Ceiling to return air plenum Right Ceiling to hot air plenum Describe ceiling construction Ceiling to first 72 of hot air duct Combustible Wall clearance Front Rear Nearest side wall (Left) Nearest side wall (Right) HOT AIR DUCT Ceiling to stovepipe Stovepipe type: Galvanized Black Steel Single Wall Double-lined Furnace to end of floor protection Front Rear Left Right Describe front wall construction FRONT OF FURNACE FURNACE FLOOR PROTECTION TYPE REAR OF FURNACE Thimble / chimney connector through wall / ceiling Yes No Wall to stovepipe Length of stovepipe Describe back wall construction NOTE: If wood furnace is an add-on, is the furnace installed (downstream) between hot air outlet of original furnace and it s distribution ducts Yes No NOTE: All dimensions shall be supplied in inches COMMENTS: X-593 wwwmymutualinsuranceca Page 5 of 5