Was the woodstove installed by the manufacturer or a licensed contractor?
Yes
Applicant's signature Date
No
Stove Informatio
Make/Name: Is woodstove equipped with a heat reclaiming device? Yes No
Radiant Jacketed
What type of fuel is used?
Circulating
How often are chimney and stove pipes cleaned?
Yes No
None
None
Yes No
Chimney Type: Factory Masonry
Other (Describe)
Clearence
1 inches side of unit nearest wall
2 inches rear of unit to wall
3 inches top of stove pipe to ceiling
4 inches bottom of unit to floor
5 inches front of unit to front edge of floor protection
6 inches size of pipe used
7 inches size of thimble or roof joist shield
Do these distances comply with the manufacturers standards?
Yes No
Remarks:
Printed name of licensed contractor/fire department official Title
Signature of licensed contractor/fire department official Date
Pacific Specialty Insurance Company
Woodstove Inspection Report
Use:
If none is selected for either of the above is this acceptable with the manufacturer?
Please sign in the space below, complete this form to the best of your knowledge, and submit it along with your signed application and one (1)
photograph of the woodstove. A licensed contractor or fire department official's signature is not required.
Policy No:Applicant's Name:
Type:
Other (Specify)
Primary Heat
Auxilary Heat
Cooking
Other (Specify)
PU1 (Ed. 4)
Floor protection: Abestos millboard covered with metal Metal Abestos millboard
Other (Specify)
Wall protection: Abestos millboard covered with metal Metal Abestos millboard
Inches
Please have a licensed contractor or fire department offical sign and complete this form in it's entirety and submit it along with your signed application and
one (1) photograph of the woodstove.
A heat reclaiming device is sometimes called a heat regulator, heat saver, waste heat
circulator or master heat circulator. This unit is attached to the stove pipe & its purpose is to
recirculate the warm air from the pipe via a fan motor. Even though the fan forces the air out
into the room, certain amount of down draft is forced down into the stove causing a hotter fire
larger flames.
Location of stove in home: Is there a smoke detector in this room?
Installation Information
(If woodstove is primary source of heat or double vented, risk is unacceptable.)
Date last cleaned:
How much combustible air space between wall
and combustible wall? (In inches)
By whom:
