HomeMy WebLinkAboutPermit Fire Damage Report 1987-8-6 (2)
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FIRE DAMAGE REPORT
OR
ELECTRICAL HAZARD
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FRO~1 :
Building Department
Springfield Fire Department
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SUBJECT: Structural Damage to Building
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Address or location of building L/C:<3o ])/J/,sy .
Name of a.mer ..:JIM .;;JO,u"":5 ( ~6eRr c";UcM'I- Dcc"-'f"l9JtIr)
Type of buildi ng &)')Gt~ ~MI L y ])tu&LL11..JG-
(Dwelling, Store, 14arehouse, etc,)
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Date of fire
Estimated loss to building $
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Location Of damage in building G/9;(fAuc
$ .:5c:J c10C?
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. Estimated value of buil~ing
~R()5"5t5 U)I1-~
, (Roof, Wall, Exterior, Interior, etc.)
Structural weakness as a result of the fire ~R()5 5ES t) Ub/( &A.Rft6E
(Burned rafters, Beams, Joists, etc.)
Additional pertinent information
Electrical Hazard fb~5/ 8L1= ~ ~/R/A)G /AJ C;+~f--
(Wiring, Outlets, etc.)
Signed ,~(d-;/7 ~AM/
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County LfbVE Dept. Responding ~9pe/AJ6-r Ie-in
o Tues S" Thur o Satur ALARM TIME ARRIVAL TIME TIME BACK IN
OWed ) 191/ ~ /lq ,I Ir ..('I SERVICE 1J
o Fri 10 [I I
ZIP CENSUS TRACT ISO CLASS (')
9171~17(f 1/ fl"tJ I z.. d ::I: 0
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DOB (optional) TELEPHONE w"'C
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ADDRESS DOB (optional) TELEPHONE tr:ltr:l
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eT ATE OF OREGON FIRE REPORT
STATE FIRE MARSHAL
_EDEPT.
ALARM NO.
~
, DO NOT WRITE INTWS SPACE
CONTROL EXP.
NO. NO.
District ~f ~.,cident
~ T to.. MO DAY
_\'PR / t.)("';f laD
o
o
Mon
DA Y OF
WEEK
YEAR
Sun
If 1& 11b117
2 INCIDENT ADDRES~
.4c:( 3D ,J~f}15 y
3 OC(jO~A:JAtVint.MIr!tJ bERi
4 BUSINESS OWNER NAME (~t, First, MI)
5 OWNER NAME (Lost. First, MIl
~A)F:5 01M
6 FIRE REPORTEU BY (Lost, Fi"'i. MIl
7 METHOD OF 0 Telephone Direct 0 Radio
ALARM 0 Municipal Alarm Syste"; 0 Verbal
o Private Alarm System 0 No Alann Rec'd
8 , OF FIRE SERVICE PERSONNEL , OF ENGINES RESPONDED.
RESPONDED '1 c2
Mutual Aid (extinguish or investigate otJ.
o Received 0 Given ~/A
o 911 (Tie Line)
o Voice Signal Muni Alarm
o Not ClassiflOd Above
, OF AERIAL APPARATUS RESPONDED
, OTHER VEHICLES RESPONDED
:#M8vt/J}vrE
9 TYPE OF SITUATION FOUND
P( Structure Fire
TI Outside StrucL w/value
o Vehicle Fire
o Brush, Grass. Leaves
o Trash. Rubbish
o Salvage
o Not Classified
o Undetermined
o Other (List)
TYPE OF ACTION TAKEN
o Extinguish 0 Removed Hazard
o Investigation 0 Stand By
o Hand-laid hose/hydrant. standpipe
o M88ter Stream Device
o Not Classified Above
o Self-Extinguished 0 AUlOmatic Ext. System
o Make.shift aids 0 Pre-connect hose/tank only
o Portable Extinguisher [Z3) Pre.connect hose/hydrant. standpipe
11 . FIXED PROPERTY USE PROPERTY COMPLEX (If applicable)
0("-\ ~~ V :Dw~L-U /...Y:s-.
M MOBILE YEAR' MAKE
PROPERTY
10 METHOD OF
EXTINGUISHMENT
MOBILE PROPERTY (Complete line M)
MODEL
SERIAL'
LICENSE'
-L!l2
EQUIPMENT INVOLVED IN IGNITION (Complete Line E)
ROOM/AREA OF FIRE ORIGIN
GARA~
E EQUIPMENT YEAR
INVOLVED
IN IGNITION
13 IGNITION FACTOR
MAKE
SERIAL'
MODEL .
VOLTAGE
14 FORM OF HEAT OF IGNITION
MATERIAL FIRST IGNITED WAS MADE OF
ITEM FIRST IGNITED:
16
VALUE
o 101.0 19f..t
o 201.0 29 f..t
Building
~r:::, 0 eX') () _00
.5500.00
o 301.0 49 f..t DOver 70 f..t 0 Below grd. level 0 Undetermined
o 50t.o70f..t o Objects in Flight 0 Not Classified
Contents Vehicle and Contents Other ;; TOTAL
/..5 ~{)OOO .00 .00 p~~a?6 .00
6dO .00 .00 .00 &tJOtJ .00
15 LEVEL OF FIRE ORIGIN
a Grade level 1.0 9 f..t
LOSS
17 ~BEROFSTORlES U 2slOries U 5106slOr;es
~ I story 0 31.0 4st.ories 0 71.0 12 st.ories
18 BUILDING AGE (In Years) I BUILDING SIZE (Gmd Fir Only) 3- 1000-4999 sq ft
/ 0 n 0-999 sa ft 0 5000-9999 SQ ft
19 CONSTRUCTION TYPE 0 Heavy Timber 0 Unprotect. Steel Bldg
o Steel & Concrete. 3-4 hr. Drot. 0 ProtecL Steel BId>>: 0 Protect. M880nry Ext. & Wood InL
EXTENT OF DAMAGE CONFINED TO: Flame Smoke DETECTOR PERFORMANCE
1 The object of origin 1 0 1 0 Olin room of origin-oper.
2 Part of room or area of origin 2 0 2 0 ~ 2 Not in room of origin-oper. .
3 Roomoforigin 3';2f. 3 0 0 3 Inrmoforigin-notoper-firetoosmaD
20 4 Fire-rsted compo of origin 4 0 4 0 0 4 Not in rm of origin-not oper. fire 1.00 smaD
5 Floor of origin 5 0 5 0 0 5 In room of origin-not oper. power disconnect
6 Structure of origin 6 0 6 g 0 6 Not in rm of origin-not oper. power discon.
7 Extended beyond structure of origin 7 0 7 0 0 7 In room of origin-not oper. dead hettery
o 8 Not in room of origin-not oper. dead battery
o 9 No detector present 0 10 Undetermined
U 131.0 24st.ories
o 25 1.0 49 st.ories
o 10,000-19.999 sq ft 0 50,000-99.999 sq ft
o 20.000-49.999 8(1 ft 0 100.000-499.999 so ft
o Unprotect. M880nry Ed. & Wood Int. 'J5..Unprotected Wood Frame
o Protected Wood Frame 0 Not Classified Ahove
SPRINKLER PERFORMANCE
I 0 Equipment operated
2 0 Equip. should have oper.-did not
3 0 Equip. present fire too small 1.0 oper.
9 0 Not classified above
o 0 Undetermined or not reported
8 }gLNo equipment present (N/A)
U 50 stories or more
o 5OO,OOOsqft
Sprinkle", Controlled Firs:
, of Heads Opened
YES 0 NO 0
9 No dsmage ofthe type (N/ A)
90
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REC~rrc:~iOnaI):
o cont. on heck
fi.g,1=:
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Y~ N
If yes. who will investigste
22 Follow Up Investigation Requested
23 Number of Injuries
r Fire Service Other
24 Me~ Ijaking Rp>ort h A _ -+-I---
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25 Additionallnfrnation by - ' -
I Number of Fataliti..
- Fire Service
Title C +:tOT:
Title J
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Other -
DateX' _ b - 8' 7
Dau I
A14-440-10 (R.A4\
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