BUILDER:

SUPERVISOR:   CONTACT #:

?  JOB

Address: 

Homeowner: 

ONE INSTALL REQUEST REQUIRED PER INSTALL. THANKS.

- Requested Install Date:

- Firebox Model to be Installed: 

1. *NTO - Permit #:   County: 

2. *Payment - Deposit Required? Yes No   PO # Required?  Yes No

3. *New Construction?  Yes No   **If no, please describe: 

4a. *How many levels on house?   4b. **Which story for install?

5. *Raised off floor? Yes No     6. *Platform Built? Yes No

7. *Framing Ready? Yes No

8. *Installation Room:

9. *Spray Insulation? Yes No    10. *Attic Shield? Yes No

11.*Fuel Supply NG **LP NA

12. *Venting thru: Roof Out Wall Chase

13a. *Building Chase? Yes No    13b. Chase Built? Yes No

14. *Cap/Pan Desired? **Yes No

15. *Roof Pitch:    16. *Roof Material:

17. *Switch **Remote ? - FOR ALL GAS APPLICATIONS

18. *Door Color - FOR WOOD-BURNING & B-VENT

19. *Gas Logs? **Yes No     Model: - FOR WOOD-BURNING & VENT FREE

*Refer to Pre-Qualifier form on back for full explanations.  

**Denotes possible extra charges. 

NOTES: 

Directions:

SIGNATURE:    DATE:

Please e-mail or fax back with desired completion date and we will respond with confirmation date as close as possible. Thanks for your business!