HomeMy WebLinkAboutPermit Fire Damage Report 1987-2-18
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FIRE DAMAGE REPORT
OR
ELECTRICAL HAZARD
DATE: ) - I V-(?7
TO: Building Department
FROM: Springfield Fire Department
SUBJECT: Structural Damage to Building
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Address or location of building _~ I 9'i<
Name of O\'mer W ~ ~
Type of building Ad- tJ ~r S~
(Dwelling, Store, I,Jarehouse, etc.)
- , QQ....
Estimated value of building S .!1('D/'DOD
Estimated loss to building S ('J ~~ fLW-,'l:OOOfJ!2...
,
Date of fire ~- I k--tf"7
/,
Location of damage in building ~ ri ~-r-
(Roof, Wall, Exterior, Interior, etc,)
Structural weakness as a result of the fire
~
(Burned rafters, Seams, Joists, etc.)
Additional pertinent informa tion
Electrical Hazard
(Wirin~, Outlets, etc,)
Signed (fj~""", 'j,..:dtv-
cc:
~ SP'-7
REDEPT(' . _.-
;\LARM NO.--.J Y; 03S J
C,14JJ
Dept. RespondinR
;~;'~Il jlj~R;V;~,~~'E . T1,~f~~'~
ZIP Cfo:NSUS THACT ISO CLASS
CfI71't(l(J t' I~ I :DI:2" "3
DOB ioplional) TEU:PHONE
~ -... tt(.NOTWRITE IN TillS SPACE ~
LC_<!NTROl. . E..XP.
,-NO. ...;;, NO.
District~f-lnCiden~ ~J.
.J I MO. I DA?' I YEAR I ~~~~F 0
~'7 0
213Drqt'~ d-w..
3 OC/f;NA~t"~~~
BUSINESS OWNER NAME I La~l. :i~llUJ
~ W ~'v"
oS OWNERNAMElLast,Fint,Ml1
- .9 ~ <;-?- 111/
STATE OF OREGON FIRE REPORT
ST A TE FIRE MARSHAL
County ~
Son DT~ 0 Thw 0 Satur
Moo l&- W", 0 Fn
ADDRESS
b50
t,k.k QJ. 5fJ)
DOB (optional)
ADDRESS
DOB (optional)
.,'
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6 r.:::;r'~~R~t:D BY (Lull. ~'iB,t t;. MillO . j ADDRESS
II~ ~ . .2.iO
7 Mi'....:....iOU <,y 0 Tt~hont Direct 0 Madia
ALARM 0 Municipal Alarm System 0 V"lhal
o PrivllteAlarmSystem 0 NoAlarm~'tP'.
8 lOr FIRE SERVICE PERSONNEL I ' OF ENGINES ~PONDED
RESPONDED er -l.
7Lfb~ 61 &,
TELEl'HO!\E
7(t;- .6 ( bb
TELEPHONE
"
1/-J5
TELEPHONE
111-/<-J3r"J
,lutualAidlutinguishorim'e&liltllteonJ)'j
DOB (optional)
9 TYPE OF SITUATION fOUND
r:g StruclUl'1! Fil'1! .
tJ Outside Slruct. w/value
o VehicleFirf!
o Brullh. Grass, Leav8
o Truh.Rubbish
"P" "JT
1Z!r 911 (Tie Line)
o Voice Signal Muni Alarm
o Not Clusified Above
I 'OF AERIAL A}>PAHA TO RESPO!'\DED
o Other{Listl I TYI'E OF ACTION TAKEN
~ Ellingui.h '. 0 Remo"oo Hazard
o Im'e&ti,ation 0 Stand By
o Hand-laid hose/hydrant, standpipe '0
. 0 Master Stream ~ice
o Not Classifit'd Above
o Received
o Givt'n
DN/A
I, OTHER VEHICLES RESPONDED
ldo not indudt' PA'a) ::z...
tl ,00 fi.COO
Ii NUZ\IHEHOfSTOHIES U 2storier. U bttl6M.ories U 13to24stllries
~ lawry D3to4.tories D7tol2stories o 25 to 49 stories
18 BUILDING AGfo:{ln 'ieata) 1 BUILDING SIZE (Grnd Fir Only) [gI lOOO'4999&qft DIO,000-1!:I,999&qrt 0 bO,000-99.99!:I&qrt
,0 ~ O.99!:1aqft 0 5000.99!19s~ft 0 20000.4!1.!jqll~o(' 0 HlOJ)OO-499.!:I99soft
19 CONSTRUCTION TYPE LJ Ht'!IvyTimber U Unprotect. Steel Bldg U Unpruted. Malllmry fo:ltt. & Wood Int. I2'S- Unprott'ctro Wood Frame
o StHl & Con<-!?lt'.3-4 hr. !?!"'. 0 Pruk't'I.St.eeIBldR 0 Protect. Ma!lOnrv Ext. & Wood Int. 0 Prolt'ett'd'''ondFramt' 0 NntClassifil'dAblwe
EXTENT Of DAMAGE CONFINED TO: Flame Smoke lH-.iECTOR PERFORMANCE SPRINKLER PEnmRMANCE
1 Tht'objrctuforigin I ~ I gJ' 0 I In room of origin-oper. I 0 F.quipmentoperatrd
2 Partofruomorarelloforigin 2 0 2,l'il 0 2 Nolin roomoforigin-oper. 2 0 Equip.sh"uld h!lvt'uper.-did not
3 Roomoforill:ln :J 0 3D 0 3 Inrmllforigin-notoper-firetoosmall 3D F..quip.preSf'otfiretnosmaIlUluper.
20 4 Fire-ratl'dcomp.oforigin 4 0 4 0 0 4 Notinrmoforigin-notoper.firewosmall 9 0 Notcl/ls-~ified/lhove
5 Flooroforigin 5 0 5 0 0 5 In room of origin-not oper. powerdiscllnnect 0 0 Undetermined or not reported
6 StroctureoforiJjn 6 0 60 0 6 Not in rm of origin-not oper. power discon. 80 No equipment present IN/A)
7 Extended beyond structure of origin i 0 70 0 7 Inroomoforigin-notuper.deadhattery
o 8 Notinl'oomoforigin-notoper.deadbattery
~ 9 Nodek't'torpresent 010 Undetermined
10 METHOD OF
EXTINGUISHMENT
o Self.E.Itinl{Uished
o Make-shiftaids
Rl Portable Elttil\l{Uishel'
fiCl Automatic Ext. System
t1 Pre-connect hose/tank only
o Prf!-cnnnt'rt h~/hydr/lnt, standpipe
IP1WPEHT'l,: C~~H'LEX (Ii a~Plic.llbJe)
I MODEL
I MOBILE PI~OJ>ERT\' (Complete line M)
I SERIAL'
EQUIPMENT INVOLVED IN IGNITION (Complete Lint' E)
6vr. .r ~ ~
MOOE)/ DO E. . I S;R;~~ '7 - .U (S 0
II FIXED PHOI'EHTY USE
)ct(,J ~
M MOBILE I YEAR l MAKE
pnOPEHTY
12 ROO~':::'RIGIN
E EQUII'Mfo:NT I YEAR '1 MAKE
INVOLVED '77.......,1 '
IN IGNITION I q , r U~
13 IGNITION FAL"1'OH
.3J..L ~~ .../. tP~
.. FORM:e:;:~ ~ y IM~TL:J"~DWASMADEO' 1'~FIRSTIG;mED'(,~
15 LEVELOf'FIREORIGIN U 1O...l9f~1 ~r~J-3~';'~" u "",,70f~1 ~"",'ml
g, Gradt'lt'vt'lto9feet o 20 to 29 feet 0 50 10 70 feet OObjectsinFlill:hl 0 NotClassifil'd
Contents VehicJt. Ilnd ContenU Otht'r
ISO,O{J{)
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"-~ "B'6'
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,00
.00
,00
LOSS
,00
,00
U bOstoriesormore
Sprinklers ControlJrd Fire:
9 Nodamall:eoflhetypeIN/A)
90
, of Heads Opened
.J 21 ::V~.4:"h~k';:::tt~I'-6-1" Jfr1- Co
V /J . 1
22 FollowUplnbl(till:8tionRA!Queswfl Y N _'>< Ifyes.whowillinve&lit:at.e
23 Numberoflnjuries
Fif"fSel"o'ice
24 Member Makinll: H.epon(R~~
25 Additionllllnformationby
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Date
::;;'-/~-,f-7
Othl'r
Other
Number of Flltalilies
Fin> Se",'ice
Title
814-440-10 (A-84)
o Salvage
o NotClas~ifird
Undet.erminl'd
I LICENSE I ~
IVOLT7E
I~ ,J.'-I/)
U Undetermined
,00
., C" TOTAL
?JO.OOO
,00
.5:DQJ
U 500,000 &q ft
'iESDNOD
o oont.onback
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FIRE DAMAGE REPORT
OR
ELECTRICAL HAZARD
/
dt ~~(Q l \~
(ft
DATE: J - I V-R7
TO: Building Department
FROM: Springfield Fire Department
SUBJECT: Structural Damage to Building
Address or location of building .~ I qR
Name of O\'mer W ~ ~
Type of building Act- f-J i2~r S~
(Dwelling, StDre, Harehouse, etc.)
oC>
Estimated value of building 5 ..:J..OO/VCO
Estimated loss to building 5 () ('~ t:Ll-cu:tS:ooofJE....
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r-/~ v;::--
- v
Date of fire ~- I f\-,f"7
Location of carnage in bui11ing
~
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,- .
r:;;t:il-r-
(Roof, Wall, Exterior, Interior, etc.)
Structural weakness as a result of the fire
~
(Burned rafters, Beams, Joists, etc.)
1) I') FrJ L-I./rt.. , u () .
. -. r
No ~~~
ff~
i?c;IJ~ -
. -
z/'-~/~ 7
~,dditional pertinent information
El ectri ca 1 Hazard
(Hirinq, Outlets, etc.)
Signed ri?.PM<.[) ~,:J..41/""
I ift
cc:
-r" . lllJ NOT WHITE IS TillS SPACE
CONTROL EXP.
~n. . SII.
...;...-" . .,~
Dirmirt of Inddent
st:JJ.
b':;-'! ;; ~ III ~EI~H 171 ~~~~,. ~
2 'INCIDENT ADDRESS
J~'~NAffd1.
~NERNM~(~r/~~
OWNER :--;AME lLast. fil'St. Mil
- ..9 o-.-.vL en- 1/>/-
3
,
6
7!L;;'DBY'W(h1k
,'I~THUlJ I.fY 0 TI'II',honl'lJirecl
ALARM 0 Municipal Alarm S)'ltem
o PrivllU' Alarm Syatem
STATE OF OREGON FIRE REPORT' ,......,,-:~ _ ..., _._
STATE FIRE MARSHAL IREDEPT, "-+,y'J_'_~,,,., -/
ALARM ~O.--""'l ,) / ,..-/-...) ,
~ D'pt.R"pondin. C,I4JfJ
~ ;:u, 0 s,'"' ;~;',TlL1.1 ;IH;V:~:; r T'l~f~~I'~
'10 ~~ n 17 l C>:NIS~~'I?D I %,0'3"
DOB lOptional) TEU':PHO~E
~
Cuunty
Sun
o Tun
J8. W"'
Mun
ADDRESS
b50
f~ rtiJ. <5r;J
DOH/uptional)
ADDRESS
DOB (optional)
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I ADDRESS
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+25"
DQRtupliunlll)
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TELEPHOSE
71b':'.6(bb
TELEPHO:>OE
"
TELEPHO~E
1'fJ -/'-/.1'7
o Hadio
o Verbal
o Nn Alarm Rl'<"dt'"
o Rt'Ct'ived
~Iutu..l Aid ~nlinF:U;" lor inn.5tij:all'unJYI
Dt->/A
~ OF FIRE SERVICE PERSONNEL
RESPOSl>EO er
9 T....PE OF SITUATION rouso
r:g Stf\JClureFire
D Outside Suuct. w/\'alue
I' OF ENGINES 2PONDED
o \'fhidl'Firf
o Bf\J~h. Grass, Le8\1ea
o Trash. Rubbish
10 ~IIo.IHOJ) OF
EXTIr-;r.UISH~IENT
o
o
:i<:I
~[f.E:ltinl/Uish~
~f8kl'.shiilllich
Porl..;)blf E~tinj(Uisher
II F1XElJ I'IWI'EHT.... USE
Ad t,J \.J-o~
>I
E
13
..
mHM~~~
Ll.:n:LOF FIR!-: OHlGIN
X (;rad~I~\I..llu9fH'1
13
16 \'ALUE
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C'"'" C 0
C
u
o
,00
C"ntents
J, 'JO,C() ()
f).COO
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,00
,00
.~I
LOSS
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~l.'~IHE/( OF S'fUmES
lii11 ~l"rv
BUILDING AGE (In ......HNI
10
3lo4sl.Oril'B
:t ~tUrLt't>
9 Nudllm.lll:cuflhe type IN/AI
90
21
22
2J
,.
MemberMllkinlt lteport (f?e.~
Additionallnlnrmotionby
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"
814.440.10 (A.841
~911(TieLine)
D Voice Sii:nal Muni Alarm
o /'Oot Classified Above
!ill
o
o
I' OF AERIAL A?PARATORESPO:\OED
o Other (Listl I TYI'E OF ACTION TAKEN
~ E:ltinguish . 0 Remon-d Hazard
o Invrslill'1l11on 0 StandBy
o Hand-laid hO$p/hydranl, standpipe '0
o MllstfrSUl'amUevicl!
o t->otClassifi!'dAbovl!
o Given
If OTHER VEHICLES RESPO:\DED
IdonutindudePA'sl c!:2..
AUl.Omatic Exl. System
Pre.ronneClh"w/tankonly
Pre.connerth(lst/hvdrant,slandpipe
II'HOI'~HTY CU~II'LEX Iii apPhC.Il11Jl'J
!\10BlLE l'Jtol'!-:RTY iCumple\.e line:-Ol/
~IOBILE I YEAR l ~lAKg
I'HOI'ERTY
12 H.OO~::'HIGIN
EQljli'~lENT j YEAR '1 ~IAKE
J~VOIXED ~Jt .
" IGNITION 1 q '7 '7 r I~.n
IGNITIO:-J FACTOR
S ~ &.<-c..A.. ,0.1 If' a,4-JL
V v I ~lATE~IALFIRSTJ(.r"I;D\\A~MADEOF
U10<"'''~1 ~"" UO"'70r~1
o ~Oto29f"'t 0 50 u. 70 feet DObjectsinFIiRht
I BUILDING SIZElGrndFlrOnJyJ ~ lOOO.49!J9sq ft
n 0.999 8q ft 0 ">OOn.~999 s{\ ft
19 (,ON~THUCTIONTYPE 0 Ht"avvTimber U Unprutt'CI.:-iu....1Bldg
o S'....I&C"nr....\p.:l.4hr.l)rnl. 0 Prnte~.t.St"'IBldR 0 Prnll!<;'I.Mai\.nnrv!-:J\.&W'K.dlnl.
EXn:NTOF !MMAGECONFINEDTO: Flame Smokp m:rECTOH PEHFOH.MANCE
1 Theubjl-ctufuriJtin ~ g; 0 1 In room ofori,rin-opl'r.
2 l'artnfruomorare8uforil{in '. 0 ~ 0 2 Nul in momoforill'in-oper.
3 R'Klm"furill:in :1 0 3 0 0:1 InrmnforiRin-nutuper-liretoosmaJl
20 4 Firf.raIKlcomp.oforiRjn 4 0 40 0 4 Nutinrmnfurigin-nutnper.firetoosmaJl
~ Floorufurijtin 5 0 50 0 5 Inroumufurigin-notoper.powerdL~cunnecl
6 SIf\JClu~offlriltin 6 0 60 0 6 Notinrmoforigin-nulfll'er.puwerdis.con.
7 Eltendedbey"nds~ructore()(origin 0 7 0 0 7 Inronmofnrij1;in-nuluper.deadbat\.ery
o 8
~ 9
1 :-010DEL
SEHIAL,
EQUIPMENT INVOL\'ED I:'; IG:\ITION (Cumpll'le Line E)
~.r~~~
>lODEr, 00 E. 1 S;H;~,:;2 '7 - .],6 (5 0
1'~2m;tD(,~
u IlbM""l!:rd.I,'vl'l
o SUI Classified
,00
\'ehicleondConlfntA
Other
,00
[, l<J I) ~u.ries
U 13t,,:!4_turirs
o
U M1l>luri....nrmore
7 to 12 ~lOril'B
2." 1,,49~If)rit'S
o Sal\'8Re
o t->otClauifi!'d
llndetermined
I L1CE:\SE;
1;~7~'iD
U Undplprmined
,00
C" TOTAL
,";.J 0, 000
. 5:0Q:j
,00
o IO.OOO.I!t.9'J9r.qft 0 r,o.OOU.99.999sqn
o 200flfl..1!l.!!<lQ ~n (I 0 100_0(Jll.4~!l.!l!l!l '<0 fj
U lJnpwlec~. Masunr". Exl. & \\"KJd Int. ~ Unprutt'C1l'd Wood Frllme
o I'rnlPCle<! ,..(~od Fromp 0 NUl ClaM'ili!'d Anewt
SI'IUNKLEH I'EHFOHMAi\CE
10 Equipml'ntllpl'rnled
o Equip._h,.uld have"IJoPr.-didnul
:10 Equip.l'rfsentfiret"usmalltouper.
9 0 N"td8~_ifi.-d1lIK've
(J 0 Undetermint'd or not reJ1'''r~
8 0 :-l'ueqoll'mt'nl present IN/AI
Nut in r'M,mornrigin-nut nper.d..adhot\.er)'
N" dtt('('lOr prewnt 0 10 Undl'terminrd
SprinkleNCunlrulledFire:
'lIfllt'ad~OI't'nt-d
jJ';;;t~"h':zI!::'~""M'~f .I-M c
tuJlnWl}Jlln(;i'ltallontu-questeP Y_ N_X Ifvts.wh"willinvI!KliRa~
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Olher
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I Ti!le
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YES 0 NoD
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