NITON WoodFlow™

Appliance Type Select Wood Stove Fireplace Insert Pellet Stove Masonry Fireplace Factory-Built Fireplace Cookstove Outdoor Boiler Fuel Type Select Cordwood Pellets Mixed / Unknown Manufacturer Model Serial Number Certification Label Seen Select Yes No Not Confirmed Appliance Certification Status Select Certified appliance Uncertified appliance Unknown Location in Building Approximate Age Age Unknown Age N/A Installation Manual Available Select Yes No Unknown Manufactured / Mobile Home Select Yes No Unknown Fuel Storage Distance from Appliance Select Less than 3 ft 3–6 ft More than 6 ft Unknown Combustible Floor Under Hearth Select Yes No Unknown Owner Reported Issues

Overall Visible Condition Select Good Fair Poor Unable to Determine Door Seal Condition Select Tight Worn Damaged Not Evaluated

Issue Severity Select Monitor Repair Safety concern Further evaluation Combustibles Nearby Select Yes No Not Confirmed Distance to Nearby Combustibles Reference Guideline Note

Installation Configuration Select Against wall Corner installation Alcove installation Freestanding / open area Unknown Hearth Protection Type Select Tile Stone Concrete Metal Other Unknown Wall Shield Present Select Yes No Unknown Connector Shield Present Select Yes No Unknown Vent Connector Type Select Single wall Double wall Double-wall vented Insulated connector Unknown Pipe Passes Through Wall Select Yes No Unknown Connector Length Connector Slope Number of Elbows Hearth Thickness Hearth R-Value (if known) Measurement Reference Note

Chimney Type Select Masonry Factory built chimney Metal chimney liner Unknown Connector Type Select Single wall Double wall Double-wall vented Insulated connector Unknown Chimney Manufacturer Chimney Certification Label Seen Select Yes No Not accessible Chimney Cap Present Select Yes No Not Visible Height Appears Adequate Select Yes No Unknown Chimney Height Above Roof Chimney Condition Select Good Creosote buildup Damaged liner Missing cap Separation / leakage Ash Storage Method Select Metal container Other container Unknown Previous Chimney Fire Reported Select Yes No Unknown

Smoke Alarm Nearby Select Yes No Not Confirmed CO Alarm Nearby Select Yes No Not Confirmed Fire Extinguisher Present Select Yes No Not Confirmed Thermal Scan Performed Select Yes No Inspection Outcome Select Appears serviceable Requires maintenance Installation review recommended Safety concern identified

Inspector Printed Name Signature Date