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Get NJ U.C.C. F370 2012-2024

CHIMNEY VERIFICATION FOR REPLACEMENT OF FUEL-FIRED EQUIPMENT BLOCK LOT QUALIFICATION CODE PERMIT WORK SITE ADDRESS Owner in Fee Verifying Individual Company Address Street Tel City Fax State Zip Code Check the Appropriate Box es Type of Replacement Existing Vent/Chimney Size Oil to Gas Conversion B Label Vent Chimney-Interior Gas to Oil Conversion Flexible Liner Gas Appliance Replacement Masonry Chimney-Tile Lined Oil to Oil Replacement Power Vent/Exhauster Other Type Fuel Type BTU Rating input/hour Oil / Gas / Other Appliance 1 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 Length of Connector Vent Connector Rise How does the appliance vent Natural Draft Height of Chimney Fan-assisted 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 Date Oil to Oil or Gas to Gas Replacements or New/Additional Appliances chimney/vent is appropriately lined and sized for the appliance s being installed and/or remaining. Direct Vent Appliance 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 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. FOR MINOR AND EMERGENCY WORK THIS FORM MUST BE PROVIDED WITH YOUR PERMIT APPLICATION* 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. I have verified that the chimney/vent is appropriately lined and sized for the appliance s being installed* Signature Date Oil to Oil or Gas to Gas Replacements or New/Additional Appliances chimney/vent is appropriately lined and sized for the appliance s being installed and/or remaining. Direct Vent Appliance I hereby verify that the appliance s being installed is a direct vent appliance. Direct Vent Appliance 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. I further verify that the existing chimney/ vent is appropriately lined and sized for any remaining appliances. Verification Not Submitted 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. .

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