FAIRWAY - Fireplace/Pellet Stove/Chimney Cleaning and Inspection Form

FAIRWAY - Fireplace/Pellet Stove/Chimney Cleaning and Inspection Form
RULES AND REGULATIONS for RESIDENTIAL UNIT

Fireplace, Pellet Stove and Chimney Cleaning & Inspection Form

This form is required to be submitted by all Owners of Units with Chimneys, Fireplaces, or Pellet Stoves

on an annual basis, no later than September 30th.
Unit #
Owner's Name(s)
Email #1
example@example.com
Telephone
Email #2
example@example.com
Telephone
Complete only one of the following sections:

Certification of NON-USE:

I certify that I have read and agree to abide by all Rules pertaining to Chimneys, Fireplaces, and Pellet Stoves. I affirm that they will not be used in the next 12 months. I understand that if I want to use them, I must submit a

new form with required information prior to use.
Owner #1 Signature

Clear
Date

MonthDayYear
Date
Owner #2 Signature

Clear
Date

MonthDayYear
Date
Certification of Inspection and Cleaning:

I certify that I have read and agree to abide by all Rules pertaining to Chimneys, Fireplaces, and Pellet Stoves.
I certify that the following were cleaned and inspected on (date)

MonthDayYear
Date
(check all that apply) Fireplace
Fireplace
Pellet Stove
Chimney
Vendor Name
(Vendor must be on the current Fairway Village Mandated Vendor List)

Proof of Cleaning & Inspection that occurred not longer than 12 months prior to form submission date must be

provided to Property Manager with this form.
Owner #1 Signature

Clear
Date

MonthDayYear
Date
Owner #2 Signature

Clear
Date

MonthDayYear
Date
Should be Empty: