Chimney Inspection & Maintenance Form
If you have any questions or feedback, please contact us at kiaora@northlandsweeps.co.nz or on 027 679 3377.
Inspection Date
-
Day
-
Month
Year
Date
Customer Name
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Type of Building
Single Storey
Double Storey
Roof Type
Flat/Membrane
Sloped
Unaccessible
Chimney Type
Straight
Elbow
Unaccessible
Roof Access Required
Yes
No
Fireplace Details
Make, Model & Measurements if required
Checklist
Safety Inspection
Status
Condition
Notes
Firebox
Yes
No
N/A
Excellent
Good
Fair
Needs Repair
Replace
Flue & Flashing
Yes
No
N/A
Excellent
Good
Fair
Needs Repair
Replace
Door, Glass & Seals
Yes
No
N/A
Excellent
Good
Fair
Needs Repair
Replace
Bricks
Yes
No
N/A
Excellent
Good
Fair
Needs Repair
Replace
Baffle Plate
Yes
No
N/A
Excellent
Good
Fair
Needs Repair
Replace
Air Control
Yes
No
N/A
Excellent
Good
Fair
Needs Repair
Replace
Air Flow Tube
Yes
No
N/A
Excellent
Good
Fair
Needs Repair
Replace
Roof Flashing and Seals
Yes
No
N/A
Excellent
Good
Fair
Needs Repair
Replace
Overall Firebox Inspection
Yes
No
N/A
Excellent
Good
Fair
Needs Repair
Replace
Bird Netting Requested
Please Select
YES
NO
Outcome
Please Select
PASS
Repair Required
Comments, Recommendations, or Feedback
Next maintenance check is due in 12 months.
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Payment
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Cash on hand
Online
Inspection Completed by
Please Select
Moses Vea
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