HomeMy WebLinkAboutPermit Fire Damage Report 2000-12-18
FD-16
~.
FIRE DAMAGE REPORT
OR
ELECTRICAL HAZARD
'~ 1~
f~ '
~ '2\0 #
no~ tft5D
(~
DATE: /;2--/<gJ((::sA
TO: Building Department
FROM: Springfield Fire Department
SUBJECT: Structural Damage to Building . I ...
,/0 4Cf C..er1 -t-.e 7'1 n.. ~
Address or location of building '5.e.~~_~r~/ 's~(,Lf~ -~"d3.t!!n4
Name of O\'mer
'$.-tt-D.loP' '~.~G.''l ;4?~}-<_:/ IL--I~
>:.,j+" (Dwelling, [tore, l~arehouseJ etc.)
Estimated value of building $ ~.c, ().(J--('l
. I
Estimated loss to building $ ;;70 o-c-C
.
Da te of fi rej -:z... -I <6 - (J',(\
Location of damage in building .S.e.~~' ~~~I -;;-:Ol::I
~~ (........tA..
(Roof, Wall, Exterior, Interior, etc.)
Type of building
Structural weakness as a result of the fire
'(Burned rafters, Beams, Joists, etc.)
Additional pertinent information
,
Electrical Hazard
8 ~n r-Y7..P~
, r
LaJ~'r~
(Wiring, Outlets, etc.)
Signed ~~~~~o~,
cc: ('()\J~ '-tD p.W 141~.. .
.'..t
- ......
. ~, ......,.
":' Il,':.'
<i
. ' . ,,"'''; .~.'",:' j '.
STA1E,OF ORECON ,,"........,;)''''' ,~m ~ ,
2000 O~N ALLJN-u~~..""-....,GS1.)..I!oLd:,
E.. .;v~...No;'
fI.--
FmEDEPr.A1N ""."
o NEW J.i. '........,.rr
OQWfGEro REPORT
~~u.J.r..IfOR ALL IN<m>ENTS
DJSTRiCTOFINODENT ~r-,~~ ~I/ COUNlY lane ..;~ &. a.:.:.< ...,,~JNG-5Pri nof.i p 1 c1 J:'; rp
I I ALARMDATE I ALARM'I'IME I DAYOF I ARlUVALDATE I ARItIVAL'I'IME I DATEBACCIN I 'IlMEBACKIN
/'?--/~-cc::::. otS~~ ...~~ ,/2.-/1f-O~ E!)~~'g /:2.-"(f-<Jo 0""'-:24-
2A PRIMARY TYPE OF ,.')u u'A'I10N ... ... VA ~(If. eft Is., .. . I.cala'Che c,peetf"cre)
fOneRepor(forEachTY1>eO(Firel '~M'r. ~..JC> ~J:r.p
2S v."...,.,. TYPEOFSlTUAnON......v......
:zc OTHERTYPEOFSlTUAnONFOUND:
SPECIAL" SIlJDIES, , J', 'FICIdl:, f' FICId2:' "":-~ICId'3:"
(LoCiJUse). l ...... '. : >-. .. ..
3 INODENT ADDRESS
1-04<:; ~n.f~ ~,j
4 ~~AME(Lase. me.MI)<<OOMPAifi'mt.-~NAME
r,.,/I~r 4-tLT,fl"..e '5
S BUS.. ..,..".OWNER NAME (Lase. firsl. NI)
,'l' ,...~~ I" ~~~~: 'F~6: .
ZIP CENSUS 'I1tACT
'1'74'7'7 '3'?
,DOS
DOS
4) BUSINESSOWNERADDRESS
7 BUJLDINCIMOBILE PRO~......& & OWNER. NAME (Last. liar. NI)
DOB
8 BUlLDINClMOBnE PRO......... i OWNER ADDRESS
9 INODENT REPORTED BY (Last. me. MI)
. DOB
10 INODENT R.<:.a- "...u:..... BY AUu~
_OFENGINES
'OF AElUALAPPAR.AnIS
~ vj'1NC
, OF 01BER. FIRE SERVICE
VEHlC1ES r.s:..>~ vNDlNC
II 'OF FIRE PERSONNEL
~,; u:.,II)lNG ..,~.. w.__....G
Cafter (~ , V~ . ',,}
U &.~.:.OFACIIONTAKEN<amcKALLnfATAPl'LY>
37 0 FaraDIe Entty 71 rH""~gare 36 OT~v... 470 Dccon.Area
15 I!r&tinguish 31 ~ 42 0 ~ ID 460 Decon PeopIo'Equip
16~entilate 32 0 Exnicate 410RemcweHazard 45 OM""';,,,. Hazmat
14~~, 33 OEMS 440EstabJishSafeAIea 430Evacuate
_.. COMPL~J.~FORALLl'~
350 Search
530 Standby
520 Move Up
o Other
. . .;'~..: 0: ."~; :'..'!:
...... ::=-...:.
u&.:>uJ,CTI
ZONE <I
TELEPHONE
<.:T'4( ) '14/-70 .s 3
TELEPHONE
( )
l
ZIP
TELEPHONE
< .)
ZIP
TELEPHONE
< )
ZIP
MU1'tJAL AID
1 0 <iIVEN 0 0 NONE
20 RECEIVED
34 0 Provide Pasonnel
740 Canceled at Scene
72 0 Canceled Enroute
. 13 PRIMARY lou:.u.uu OF ",^uul:OUISBMENT
7 0 WaJa From TankcrlI'eodc:r Shuttle ..
8 0 Ground Crews WI Equip And/Or Air S-t'r v...
90 Method Not aassified Above
1 0 Se1f-Extingui.shed 4 0 Aut."......:~ Extinguishing System
2 0 Makeshift Aids S 0 Wau::r Omicd On Initial At-yo.......JS
30 Portable ~sher 6 JKVatcr From H, :.,,,..,.. Draft Or Standpipe
J4 PRJMARY ACENTOF .l:.A>u<lCWSBMENT
lli"\\"aterOnly 300assAExting. 500assAIBICExting. 70<::02 90c..__->.>~jAir:-".....11 oOassBr.......JAFFF 13 o None
20 Dirt 400assBIC~ 600assDExtinfr 80HalOD 1000assAFoam 120Weuin1?;A~entW/Water 1400ther
15 SPECIFIC PROPERTY USE ....,..........u.PRO~......,.IUSE MOBnEPROPERTY INVOLVED (C.-rl...IiDeM)
~*IU. .~. ~4!"000a. saUAU/AlRCRAfTtAlL' {UCENSU
16 ROOMlAREAOFFlREORIGIN J EQUlPMENTINVOLVEDJNIGNmON (CompictelJDe~
'Se~ ~"'I &JI.. ,~,I'~~
E , YEAR . MAKE 1 I NODa.
J1 IGNmON FACTOR
I STAle
SERIAL'
I POWER SOURCE
'IOFIXED
20 PORTABLE
Namberol
.IuYcaiIes:
Elderly Pbyslc:aIIy Nu!liple I'c:aom
(Age 65+) 0" Disadvanugod 0 Jmoolved 0
J8 HUMAN FACTORS - Asleep - I 0 MaIc . U. ....J.:.. .,.~. U........, ~d Pcaoa JIn'CIIiIe 0
INVOL VEl> IN 0 20 Female 0 0 Put Age and GcDder ill
IGNITION R.EMAIU<S
19 FORM OF HEAT OF IGNmON MATERIAL FIRST IGNITED WAS MADE OF
ITEM FIRST IGNfIED
20 LEVEL OF FIRE
ORIGIN
2I ESTLMA TED
VALUE
I 3 0 Abo>'C Grow><! <4 0 In flip
Mobile r"" _.... and c.._~ 0dIc:r
.00 .ro
I 0 &low Ground 2 0 (jJOUDd Le..d
Buildiag Coateuts
,00
22 =.u-iATED
LOSS
,00
,00
,00
I f100c of OrigjJl
(Sauaure Fires Ooly)
TOTAL
.00
.00
,00
,00 ,
. ....~.:...~ .. ...;'...... .'.:. .
. ' ,,' ~,~MPf4,....;.FOR"Ai..LSrRtk...u~'FiRF"; :~~ .'0;.:",'
. 2S =:: Yca<s . IlVIUHI'lCSIZE~'~OaIJt' 305000-9mSQI'I":'i\'f:;~""" 410~ JSQfI',
, A ^ CIa ) 100-mSQ1'f 401o.000-19.mSQI'I',:.. 70 JOO,OOlt-4ft.CIOOSQfI'
TV . 2~-4999sql'l' 'SO 20,000-49.msqfI', ' .0~SQFToR.NORE
Z4 STlUJ",Au..ETYPE ()()NSI'RUC'[IONTYf'E ' llOOFOO'~ '
. ~.;!.~_jScn1c:tuR: I OSfoccl &:C. ,......;,3-4Hr 100assAOrB~C"..,. .~:.bIe;MeaI. "IiIc.O'.._......l:~
30 OpcaS". .,.,. (NoWaBs) 20f.w........d~ExL&Wood lat., 2.lksissCC. '"t .."... ..<<F'o;o_w.].Man(AspbakSbL...:_
40 Air.~.'U..,.:fSauctUIe 30~t.~._.#,ExL"Woodlnt. 300assC(Tlealtllh~~Wood~t...} ~
SO Tent 40r... ,.~St=lBIdg. 40U~u~.4Woods:.:....-
60 Opca Platform (NO Roof) 5 0 ~ Steel Bldg. 50 NOlU3tC4 RoofCoYaiDg (Canvas. Pbsdc, HocTar)
O (jOHeavyTUDbc:r 80::..,....:..... Wl1hoatRoof
7 U..l_v._JSUtIClW'C 7~Woocffumc 90Roo{NotQasscclAboYe
90 Type of S~ NO( Qass'd .Abooc 11 0 U.....w_.-:d Woocf Frame
90 Type Not Oasscd Above
%5 I'RlMARY FA.... "'A o)l'o"TRlBUTING 1'0 FLAME TRAVEL
EXIENT OF DAMAGE CAUSED BY
. SMOKE
1 0 Object of Origin
20 Part ofRoomIAn:a of Origin
30 Room of Origin
40~ Comp.ofOrigin
S 0 FIool' of Origin (Mulli-tloor' Bldg)
60 Suuawe of Origin
10 r..J .~:f Suadure of Origin
90 No J)ama..oe of This Type
.AUBM POWER,>uJ: J: AJY
10 BaucryOnly
20 Hardwin: Only
30 Plug in
40 Hardwin: wi Batta)'
SO Plug in wi Baaay
60 Mecha!Ucal
70 Mulliple Alarm "Powa Supplies
:u
f1.AME
I 0 Object of Origin
20 Part ofRoomfAla of Origin
3 0 R~ofOrigin
40 Fin>arcd Comp. of Origin
SO HoocofOrigin (Mulli-fIoorBIdg.)
(j 0 Sauawe of Origin
70 Beyon<I S-.__ofOrigin
80 Non-fire Dama,..oe Report
rT .ALARM TYPE
1 0 ::'...1-
20 Heat
30 Combination SmokcIHeat
40 Sprinldc:dWata' Flow Almn
S 0 ~t'.....:..I Ha=d Sys Rdcasc Device
60 More 1han One Type Present
70 Catbon Moooxide Almn
80 NoAlann pr=t
~ 0 Olbci-Type of Almn Present
00 Alarm UnIa1ownfuot ~
2& M&U100..ER~TYPE
1 0 Wet Pipe System
20 DIy Pipe System
30 Dc:luge System
40 ~OD S)'StCID
SO Comb. DIyP.ipe k ~ System -.
6 0 "'()Q.Ofl" SpDnJ:Ier Heads
70 Opc:u Head SystcII. Manual Conaol
8 0 NoSprin1:Jc:tI'...."';.~
OOTypeSys. U_"T"".IIU~:...;~
NUMBER OF BEADS OPENED
. :..~.~: '.'
..... ~-.... ..
,. '.~' .:',.
::. ..:,":
. ~.~, .,.....~.. :
troMBEROf .......JES " ,.
(Noc~E. .....'.., ..:
';L .
..
;.. ..~..:
. .. . -. --
, I'lUMARY AVENUJ::OF:>MOlU;;.lRAVEL
EIRESVPPRESSlON &r!!.~ S!!.1Jf....11!ED TO
EXIINGUISBINGAGENT HIU,.U)L'U1<.Ut.
1 0 Object of Origin 1 0 Object of Origin
20 Part ofRoom'AIa of Origin 20 Part ofRoomfA1eaofOd8in
30 Room ofWgin 30 Room of Origin
.0 FUoaD::d Comp. of Origin ' 40~ Comp. of Origin
SO FIoocof Ori.,<>in (MaIti-fIooc Bteig) SO HOOl'ofOrigin (MaltHlOOl' Bldg)
(j 0 S_____ of Origin (j 0 Sau<;tw:e of Origin
70 BC)'ODCl S.. .._. of Origin 70 Beyoo4 Sauc;am: of Origin
90 No ~ of This Tpe 90 No I>aJna!!e of This Type
ALARM PERFORMANCE REASON FORAIA.RMFAILURE
10 In Room of OriginlA1atcd C..........- 1 o IL_::,,:'_J Power Sopply Failed
20 NO( in Room IAlatcd 0cc:upanlS 20 L.....~r...:InstallaIion orPL.____.<
3 0 In Room of OriginlDid Not Op=tc 30 Dc:fc:ctiyc.Alaon
40 NO( in RoorolDid Not Opaat.: 40 Jn3dequ.a1e MaintaW10C
SO PIescnt in R()()In/I;n: Too Small SO Baaay Missing or Disoonnc:cted
(j 0 Ct' _.:._JINot Fadorin Disoovay 60 Baaay Disdwged
70 Cr _.....dIOccapanlS Failed to A1::1 80 No Alarm Failarc
OOFailarcUw':_"':. .J
SPIUNKLERPERFORMANCE
1 0 Opa:atcd &: Contro11cd/ExIi'd Fire
20 Opa:atcd &. Not CoutxoI/Exling. Fire
30 Sbould haYC <;..........vDid NO(
40 System PI\:scl1tIFiIe Too SIIl3II
80 No Eqaip in Room of Origin
OOFJ__.'U-."2'.._J
REASON FOR SPRINKLER FAILURE
1 OSystcmSbatOfl'
20 Not Enough Apt to Coattol Fire
30 Apt Could Not Reach File
40 System Piping Damaged
S ONo Heads In Room of Origin
80 No System Failun:
o 0 ~ CorFailarc U_ -a- ....J
COMPLETE FOR ALL INCIDENTS
IF YES, WHO WILL I. 0SfM 2. Local fD 3. OSP .. Loca1I'D/Sb:1ift'
I il-'t€s INVESllGATE // / J
, Name: ':Jd,.~~r.p.fQ rnr_
NVMBEROFT I tlRE~
FATA/111E.S ~
~., At ~~ ~~ mu ~oi-:
NAME - -. - - mu ' ~
, ",. FOUOW UP INVESTIGAnON
~"'.......,... OONO
30 NUMBER OF
INJURIES
31 MEMBER
MAKING
FIRESERVI<t'S'
OAD.I:oOI. ...(S"
au:.cV~.I.
32 ADDmONAL
INFORMATION
BY
,. Od>crPasoafA&caeY
~~.L-tl
u"~6
DA.TE
~'7--/8-f:s-('
DA.TE
'.I
33 SPECIAL OSFM STUDY: Was tbis.....r.......e delayed due to aoc:ess c1itIicu1ties resulting from D21TOW streets? YES. NO.
J!YES, please descn'be in remarks. ..
_ ,_..u ._._ ---
- .11_1_1 _. .
Juveniles Involved(CcmpUu JItVDlik wlFue FormlOJ)
Juv. #1 Juv.412 Juv. #3 Juv. #41
l
Me
Gender
~3-10(R2000)
REMARKS