Chimney Cap Request Form
Company
Company Name
Salesman
Contact Phone Number
Please enter a valid phone number.
Contact Email
example@example.com
Customer Name
First Name
Last Name
Customer Phone Number
Please enter a valid phone number.
Job Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Chimney Type
Please Select
Brick/Masonry
Rock/Stone
Wood Framed/Hardie Siding
Other
Other Description
Cap Style
Please Select
Style A
Style B
Style C
Style D
Style E
Custom
Description of Custom Cap
Upload photo of what you are looking to have made
File Upload
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Color
Please Select
Matte Black
Charcoal Gray
Galvalume
White
Burnished Slate
Copper Metallic
Custom
Custom Color
Please tell us what color you would like for your chimney and who supplies that color
Dimensions
Please measure all four sides of chimney
Front Side (inches)
Back Side (inches)
Left Side (inches)
Right Side (inches)
Height (inches)
Roof Pitch
Please Select
1/12
2/12
3/12
4/12
5/12
6/12
7/12
8/12 - $50
9/12 - $50
10/12 - $50
11/12 - $50
12/12 - $50
Upload Sketch or Photo
Browse Files
Drag and drop files here
Choose a file
Cancel
of
NOTES OR OTHER DESCRIPTERS
Add Spark Arrestor?
Yes
No, use existing one
Delivery
Please Select
Pickup
Delivery $150
Date
-
Month
-
Day
Year
Requested Completion date
My Products
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next
( X )
Chimney Base
$
350.00
Quantity
1
2
3
4
5
6
7
8
9
10
Chimney Base with Spark arrestor
$
450.00
Quantity
1
2
3
4
5
6
7
8
9
10
Chimney with base and sparker arrestor
$
650.00
Quantity
1
2
3
4
5
6
7
8
9
10
Custom Chimney with base and spark arrestor
$
1,250.00
Quantity
1
2
3
4
5
6
7
8
9
10
High Pitch
$
50.00
Quantity
1
2
3
4
5
6
7
8
9
10
Delivery Charge
$
150.00
Quantity
1
2
3
4
5
6
7
8
9
10
Submit
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