HomeMy WebLinkAboutPermit Fire Damage Report 1991-12-5
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FIRE DAMAGE REPORT
OR
ELECTRICAL HAZARD
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DATE:!..?- 5"", ~I
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Building'Department
Springfield Fire Department
. FROM:
SUBJECT: ',.Structural Damage to Building
Address or location of building
. Name of, m.mer. . R..., b ev-- -+-
S2. 5'tf
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Type.Of building 11-10 h~ 'e... h."......e. ('S':"',lc -PdW>')'1 dv.><:./' 'I-c.j)
(Dwelling, Store, Warehouse, etc.) I
Estimated value of building $
So ,00 0
5u c)o D
J
'.'
,E,stimatedloss to building $
Date of fire. 12- 5 - 'j /
Location of damage in building
c"'- -h'-e ") -+ r- ..... L ~v-e...
.-
(Roof, Wall, Exterior, Interior" etc.)
Structural weakness as a ,result of the f,ire .f' /00.- , c e;
/,...... . w4lb
(7
;'
(Burned rafters, Beams, Joists, etc.)
Additional pertinent information
Electrical Hazard .ill/ '" /<=.c. -I.
e"'r"'-.'t.?~+ cb'<:l""'.'lrri
cc:
(Wirinq, Outlets, etc.)
Si,oed 71f~~L~)
Df'pt. Respondin~
OA~A~M ~I;E 410 A;~V:L;'~12
ZIP CENSUS TRACT
'11:U11-h8 I "I? t 61
DOB(optionall
1-j~ - 6:2.09
TELEPHONE
,J n() ~OT WRITE 1:-1 TillS SPACE
CONTROL E.XP,
1\0, NO.
ST A TE OF OREGON FIRE REPORT
STATE FIRE MARSHAL
.l...RE DEPT.
_ARM NO.
.
Dstrictoflncident So ",~'"'\q -r; ~ \ A
II ~~ 16D:~II';~;I,1 ~~~~F
INCIDENT ADDRESS -+:
OCC!~!.~LuI.Finl.M~ r- '5 '1 ~l~ I l1-
Ro ~ ~I"-+ KO'$C'h
BUSINESS OWNER NAME (Last. Fin.t. Ml)
S~lYlv
County J Cc...~, r-
o Tues
o Wod
o Satur
M,"
l2i
o Fri
o Sun
o
Th..
5.,3' '1 ~
. ADDRESS
DOB (optional)
ADDRESS
DQB(optional)
5 O'WNERNAME(Last.Fint.MI)
3.i'l""~
6 FIRE REPORTED BY (Last. Fmt. MIl
3aW\e. \. pav',~ K05e"t'l I
o Tele::lhone Direct 0 Radio
o MunK:ipal Alarm S)'5tem 0 Verbal
o Private Alarm System 0 No Alarm Rec'd
8 lOFFlRESERVICEPERSONt>."EL I ;OFENGINESRESP07"ffiED
RESPONDED IIf .J
ADDRESS
DOB(optional)
Stl~
C' 'f" (
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I 'TIMEHACK Il\
SEH\'ICt-:
OIZ 13 13
! l IS'3L,^'
TELEPHONE
TELEPHONE
TELEPHONE
Mutual Aid (utinguu., or investigattonl)'}
Recel\'td 0 Given ~ N/A
,0..911 (Tie Line) I
o Voict'SignaJMuniAlarm 0
o Not Classified. Above .
I' OF AERlALA~PARATUS RESPONDE?
o Other (List) I TYPE OF ACTION TAKEN
~ Estinguish 0 Remo,'ed Hazard
o In\'estigation 0 Stand By
o Hand.laidhoae!hydrant.standpipe
o MuterStreamne..'~
o Not Classified Above
METHOD OF
ALARM
I ' OTHER VEHICLES RESPONDED
(do not indude PA's) .3
MOBILE PROPERTY (Compll'le line M)
P1" h;'c:.
I MOD~ ,If')( tp ()' SERIAL I I LICENSE I
. ~I~MENT IN)\OL\'ED IN IGNITION (Co~}l'k Line E) . +.s b' J .
T.V. ~ 4!u.e.,Sa.y-) Vc...R-1h1 U IsnL
I SERIAL'
U 13to24slOrirs
o 25 to 49 stories
U IO.OOO.19.999aqft D SO,OOO-99.999sqft
o 20.00Q.4lfJllflf 110 ft 0 100.000.499.999 act ft
U Unprottct. Masonr)" Ext. & Wood Int. ~ Unprotecttd Wood Framt'
o Proll'<:ttd Wood Frame 0 Not Classified Abo\,t
SPRI:"\KLER PERFORMANCE
10 Equipml'ntoperaloo
o Equip. should havl' oper.-did nOI
o Equip. preM'nt fin" 100 small to oper.
o Sotdassifil"liabo\'l'
00 lIndett'rrnint'do: nul reported
S~'\<'Kluil'mt'nIPrf'st'nt\S!Al
9 TYPE OF SITUATION roUND
RStructureFire
D' Outsidl' Strucl. w/,'alue
o Vehicle Fire
o Brush. Grass. Leaves
o Trash, Rubbish
10 METHOD OF
EXTINGUISHMENT
o Self-Eninguishtd
o Maltl'-,hift aids
o Portable Extinguisher
o Automatic En. System
o Pre.connKt hose/tank oni)'
t)i{ Pre-connl'Ct hoae/hydrant.l~
I PROPERn' COMPLEX (If applicable)
I~""'c..
11 FIXED PROPEF1' USE
:;:jn<; It' -h-',)... d"",,1 j,!'I
M MOBILE I 'I'EAR I I MAKE G
PROPERTY t 7- CDr-, 1'\ .hc...v-
"'~2 ROOM/AREAOFFlRE~IGIN
) S. 'S ;,1.. 0+ /, 'u 10--J r-ool"l'j
E EQUIPMENT I YEAR I Mi)C'E
INVOL\'EJ)
IN IGNITION
13 IGNITION FACTOR
'fY\O:::.t 'eI"'DIoa...\o~
14 FORM OF HEATOFIGl"TTION ..... I MATERIAL FIRST IGNITED WAS MADEOt _ J II lITEM FIRSTTGNITED:
5''''M--t~<DV~~ \~r>1- \P..."lor..lol......V\Q.s~LG ~k:.
15 LEVELOFFIREORIGIl" U IOtoIlftet U 30to49ftet U (h'er 70 feet
~ Gradfl~'elto9feet 0 20to~ftet;. 0 SOto70ftel DObje(tsinFlight
16 VALUE Building :2' Contents Vl'hicll.'8ndContents
.1)0 DO 0.00 :A 'f 000.00 I {) 000
.Jd o~ ()
MODEL
~hc.J- o-'t ()ll~~-f'v-c.
rri t: II.
lib If e tr._
U BeIoVlgrd.lm'el
o NOIClassified
Other
.00
.00
LOSS
.00
:;. 5,ooe)
.00
....e--
.00
.00
.
1 i NUMBER OF STORIES
~ lsto~.
18 BUJLDINGAGE(lnYean)
U 50 fitories or more
U25tori5 U 5to6atories
o 3tohtories 0 itn12stories
I BUILDING SIZE IGmd Fir Only) ~ 1000-4999 sq ft
I] O.999.aqft 0 5OOO.9999~ft
19 CO:\STRUCTIo=--n'PE U HeavyTimber U Unprottct,SteelBldg
o St.tel&Conc~u,,3-~hr.~rol. 0 Prott"Ct.StteIBld2 0 Protect. MalOnn' Est. & Wood Int.
EXTEl"T OF DAMAGE CONFINED TO: namt Smoke DETECTOR PERFORMANCE
I ThfobjKloforigin 1 0 I 0 ~ 1 In room oforigin-oper.
! Pa"ofroomorareaoforigin 2 0 0 0 2 f'.;otinroomoforigin~oper.
I Roomoforigin 3 0 3 0 0 3 Inrmoforigin-notoptr-I'itt'lOOlmall
20 I Fin".raledoomp.ofonpn 4 0 4 0 0 4 Not in nn of origin-not optr. fire too small
Flournfuri!-,in 5 0 5 0 0 5 Inroomoruril!in-notopt'r.p"\IOerdi~cnnnert
Slnlcturt'ofor;!-'in 6 0 60 0 6 :>:ot inrm<lforiRin-nOI oper, po"..er discun.
Exlendfd beyondslructUn' nforij;:in ~ ';)SI 0 Inroomoforigin-n(lIOpt'r.deadbalt.e~'
08 :\ot in room uforipn-no(opt'r. dud balt.t'f)'
o 9 No dt'lecwr prt'sent 0 10 l1ndelt~rmin\'d
~prinkler~ConlrullKl fift':
, 01 Head~ (l~lt'nt'd
I, S"dllmIlRt' of the 1)'Pe INIAl
90
2\ IlEM!\RKS WealherCondilion~lnplionan:
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Y..),;:.... N
Ifyt's,who,,'iIlinnSliJ,:lIte
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22):suJ ~nnfU.qut'slt'd
'(> :~lImt~r"f Injuries ,
'- Flrt' Ston'i{'f' "
Sumberurrallllilit'S
Fin.St.rvkt'
Titlt, ~ ._
1.-41,1., -,
T;," D F (Jl
1fR-
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:!f, }rlrlili,onlllInf"rmHli"nb~O(~O dL ~-f.::..e-,'\...
o Salvagr
o NotClassifitd
o Undetermined
I VOLTAGE
Surd-eM<\',
.
U Undetermined
TOTAL
1:1 _'S".OO 11 ,00
'7 ~ ()CTt) .00
U 5OO.000aqft
YES 0 NoD
o nont.unbad,
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