The URL can be used to link to this page

Home My WebLink AboutPermit Building 2001-03-13SPRINGFIELD Job# 01-00228-01 RESIDENTIAL PERMIT City Of Springfield Community Services Division Building Safety Page 1 of 2 225 North Fifth Street Springfield, OR97477 Location Of Proposed Site: 1530 00009th St Spr AssessorsMap#: 17032642 Lot: Block: Addition: Job Number: 01 -00228-01 Office:726-3759 lnspection Line: 726-3769 Tax Lot #: 04601 Subdivision: ctrY oF SPRTNGFIELD, OREGO^ Owner: Joanne Jones Address: 1252 Willigillespie Rd Scope Of Work: Fire Damage Phone Number: City/State/Zip: Repair 541-345-12s2 Eugene, OR 97401 Value: $18,000 Kitchen fire- Replace sink, 3 rms. of sheet rock, add exhaust fan Contractor Type GeneralContr ElectricalContr Plumbing Contr Contractor Ehlers Construction lnc 2066112 Roosevelt Blvd, Eugene, OR 97402-2536 Crow Valley Electric lnc Po Box 22201, Eugene, OR 97402 R & s Plumbing 2234 Dakola St, eugene, OR Registration # 4231 Expiration Date 11119t2000 Phone 541-689-6177 541-729-5108 541-461-4714 9591 0 1t6t2001 Quad Area: # Of Units: Constr. Type: Water Heater: Office Use - Land Use: Zoning Code: Bedrooms: Range: # Of Buildings: Occupancy Group: Heat Source: Sq. Footage: To request an inspection callthe 24hour recording at726-3769. All inspections requested before 7:00 a.m. will be made the same working day, inspections requested after 7:00 a.m. will be made the following working day. Required lnspections Building Ceiling !nsulation Walllnsulation Drywall Rough Electrical Final Electrical - Prior to cover. -Prior to Cover -Prior to taping. Etectrical I - Prior to cover. -When all electricalwork is complete. ptumbins FinalPlumbing -When all plumbing work is complete. Job# 01-00228-01 Page 2 ot 2 Required lnspections Mechanical Rough Mechanical FinalMechanical Construction Types: Occupancy Groups: # Of Buildings: # Of Bedrooms: Handicap Access? Area (Sq. Main: -Prior to cover. -When all mechanicalwork is complete Accessory # Of Stories: Height (feet): Current Units: Proposed Units: Census Code: Does not apply Total: Paid On Receipt# Value/Quantity Fee Amount Building Permit State Surcharge For Building Permit Building Administrative Fee Total Building 03113t2001 0311312001 03113t2001 4661 4661 4661 18,000 $128.50 $e.00 $3.86 $141.36 Electrical Branch Circuits WO Feeder or Service State Surcharge - Electrical Administrative Fee - Electrical Total Electrical 03113t2001 03t13t2001 0311312001 4661 4661 4661 2 $37.00 $2.59 $1.11 $40.70 Plum Minimum Plumbing Permit Fee Number of Fixtures State Surcharge - Plumbing Administrative Fee - Plumbing Tota! Plumbing 0311312001 03113t2001 03113t2001 03113t2001 4661 4661 4661 4661 1 $5.00 $10.00 $1.05 $.45 $16.s0 Mechanical Hood and Exhaust Minimum Mechanical Permit Administrative Fee - Mechanical Mechanical lssuance State Surcharge - Mechanical Total Mechanical 0311312001 0311312001 03t13t2001 03113t2001 03113t2001 466't 4661 4661 4661 4661 1 $4.50 $10.50 $.45 $10.00 $1.05 $26.50 Grand Total By signature, hereby certify I state and agree that I have carefully examined the completed application and do that all information herein is true and correct, and I further certify that any and allwork performed shall be done in accordance with the Ordinances of the City of Springfield and the Laws of the State on. I further state that only contractors and employees who are in compliance withof Oreg .055 wiloRS 701 I be used on this project. I further agree to ensure that all required inspections are requested at the proper time, that the project address is readable from the street, that the permit card is located at the front of the remain on the site at alltimes during $225.06 sig , and the approved set of plans will Z 3 o Fee CITY OF OREGO'V #;liilir %3'""]T: iri* ffi:i,;: ffi f l[:,, SP. ;FIELC' Ci ty Nev Residential-Single or Multi-FamiIy per dvelling unit. Service rncludedt ,a"*s cost BI,ECTRICAL PERHIT APPLICATIO- Pq afr, 225 FIFTH STRXET Zoning (- SPRINGFIELD, INSPECf,ION REQTIEST:o,,t8,9al38?",,," OFFICE: 726-3759 1 OF INSTALI.,ATIONt\ DESCRIPTION cit Supervisor License Number tl ?\l 73 Exp iration Date Constr Contr. Number 1 9th Expiration Dat " tll!7-<\ Signature f Supervising Electrician Ovners Name Address DATE: Job Nurnber -OO"-zb -(9 rEE SCMDULE BELOV -ol 3 A JOB DESCRTFTION{i t a F' ?u ta -@ &t*"d,'ao Permits are non-transferable and expire if vork is not started vithin 180 days of issuance or if vork is suspended for 180 days. 2. CONTRACTOR INSTALI^ATION ONLY Electrical Contracto Address Phone L{3t 5tr,} 1000 sq.ft. or less Each additional 500 'sq. ft or portion thereof Each Manuf 'd llome- or Modular Dvelling Sertice or Feeder s 8s.00 s 1s.00 s 40.00 Services or Feeders Installation, Alterations or Relocation: 200 amps or less 201 amps to 400 amPS - 401- amps to 600 amPs - 601 amps to 1000 amps- Over 1000 amPs/volts -- Reconnect OnIY Temporary Services or Feeders Insia1laiion, Alteration or Relocation 200 amps''or less 201 amps to 400 amPs --_Over 401 to 600 amPs over 600 amps or fOOO-voTts Branch Circuits Nev, Alteration or Extension Per Panel one Circuit _.-- g 35.00 f,g Each Addi tional Circuit or vith Service or Feeder Permi t / S 2'00 2g- Miscellaneous (Service/feeder not included) -Each installation Pump or irrigation -..-Si.gnloutIine Lighting..- Limited EnergY/Res - Limited EnergY/Comm SUBTOTAL OF ABOVE 7% State Surcharge 32 Administrative Fee TOTAL B Sum ee "Btt a6ove D C E s s0.00 s 60.00 $100. 0o s130. 00 $300.00 s 40.00 $ $ $ s s 40.00 s 40.00 s 20.00 s 36.00 40.00 55.00 80.00 c:,w &t4,1tO Phon'- 4Sy'zfL OI]NER TNSTALLATION The installation is being made on property I ovn vhich is not intended i00:,I$p$Ufll1e, lease or rent' ,i? Ul$o*"ox!1s1Bsu r e : -i00i tT HUl,i: liu0 5T r-1r-r RECEIVED BY: 'l .00:,!liH5u3 : l5i'luHxlO'qii $ i:03iH lt{U |00i iI ,}ul.J: il-ufi I?!rt000- Iil : #5i.iH,t1 I ,,#a:;rffi;H^,kBlffi*F:rREDErr. Ar -No.Ol_ OAq1A1 ElooSuneNo. INcpeivr tr Reponr rtl DEpr. REspoNDtorc-Spli&glif.fg[_Lif€_LaneDISTRTCTOFCOUNTY INBACK5-oaDAYOF WEEK-o 2A PRIMARY TYPE OF SIIUATION FOIIND: Or r fin is inolvc4 colcr rhc tvpc of firc) OTIIER TYPE OFSITUATION FOTJND: 3 2C OTIIERTYPE OF SITUATION FOUND: F*ld 6:'' Fi:ld5:'Frdd&.FEldzSPECTALSTT'DIES Or&t usc) At DISTRICT/ ZONE?*.t?* CENSUSTRACT333 INCIDENTADDRESS ) 53D ?o :*. DOA TELEPHONEt?ql) g+'tzp TEI.EPHONE () DOB AP6 BUSINESS OWNER ADDRESS DOB TELEPHONE ()Truu.onc,}roalrj PRoPErrrr owNER NAME G:s( Eri. r,{D ZI?E BI,'ILDING4UOBIIJ PROPERTY OWNER ADDRESS TELEPTTONE()DOB9 INCIDENT REPORTED BY ({rs( Es( MI) zlP10 INCIDENT REFORTED BY ADDRESS OO NONE r OFOTHERFIRE SERYICE VEX'ICIJSRESFONDING Z,A,. ,OFENGNES N.ESPONDING3 'OFAERIAL APPARATI'S R.ESPONDTNC o II 'OFFIREPERSIONNELRESP'O}IDING cr.ccr /2-lva,a.ct 37 tr ForcibleEotry f5 trEniaguish l6BVcotilatc Tlflorcsigac 36trTrasPort 3t OResanc 42trllazmalD 32trExticatc 4l trRemotrcHazard 4TBDccon Area 46trDconPcoplc/EquiP 45BMonitorHaaat 35 trScarch 53 OSandby 52 tr Movc Up 34tr PnovidcPcrsoorrl 74OCan€lcd atSceoc 72 tr CancclcdEarqtc THATx, 43trt4B/l[Ea - FOR ,+\\ 3t 4 tr Automatic Extiaguishing Sfistco 5 tr Watc( Cardcd Oo Initid APParas 7 tr Vr'arcr From Tankcr/TcodcrSbutlc 8 O Ground Gcurs \[r/ Equip Atrd/Or Air SuPPort r:r 9tr OassifiedAbovc60Draft I tr Sclf-BdiDgpistrcd Aids tr 2 3 9 tr Cooprcs:ed AirFoam I I O Class B Foas/AFFFl.t 4 ClassWC 13 tr None5 O Class A/B/CF-rtiag 7 A@2 D l0 tr CXass t2cj Watc( 14 l(V/atcrOoly 3trCtassAExting- trtOgtl.E PROPERTT INvOLYED (Cmi3lac frc M]GENEBALPR,OPEETT USE15 SPECIFICPROPERIYUST 6lnp lcx' UCENSEiSERIALI/NRCRAITTAILIMODELMYTARMAKE ricE)16 ROOM/AREA OF FIRE ORIGIN TOFDGD 2OFC'RTABI.E POWERSOT,RCESGRIALIEY:EAR MAKE MODEL b **her\.*\ o*- FACTOR q.- MoliplcF.tsG tnrohrcd tr nytrfy Ofrdtrlrgca tr Edcrly (Aec65+) O t.lrdcrof Jscsiks: Jrrtrdc O hnAserdCrcndcrb REMARIG Uaracodcd Ptrso tr It EI'MANFACTORS INYOLVEDIN IGNITTON AlccA a(l OMde 20r.cmlc Umoscirs B FIRSTICNTTED Oa\c-cc> RnsrtcxrrrowAsMADEOF tI MATERIAI. erl 19 FORM OF IIEAT OFIGNITION e \c-{ . Floo< of Origio Guuctrre FIrcs OnIY)4 O to FliSh!r Eetorrccrrouoat E Bcl'ow GrcqDd 2OGMEdlrwl2{) I-EVEL OF FIRE ORIGIN .00 -Toi"AL lto.@o Otls .@ Mobib hopatyead Coucc .@ Cootors /o,@ o .oo 2I ESTIMATED VALUE BuildinS /&.eO .@ 6,o:9----------.@.@La>o .ooSreO .oo 22 ESTIMATED I A ztP MUTUALAID I O GI\IEN2N RECEII/ED llOrha (i, |.)....- LOSS rt FOR (tlatrcbarg S.sctEtu)2EUILDINGSf,ZE l Oo-999sQFr 3tr 4tr 50 dY) zE t@.@o-.99.ooosQFT 60 r:l5oo0-9999SQFT lo,00o - 19,999 SQ FT FT4999 B EUtLDING abscoY6) I O Class A Or B (Non Combustibla; McuI, Tilc' Composition) )Qctass C Compcirion or Prtpared, Mat'l (Asphalt Shinglcs) 3 OCtasr C (Trcat d ard Listcd Wood Shiadcs) 4 O Unrrcatcd Wood Shioglcs 5 B Nonratcd RoofConcring ( Canvas' Plastic' Hot Tar ) 8 O Strucorc Without Roof 9 O RoofNotClarscd Abovc I O Stccl & Concrac' 3-4 Hr 2 O Protcctcd Masonry E'xr. & Wood InL 3 OUnprotcctcd MasonryExt &Wood hL 4 O Plotcdcd. Stccl Btdg. 5 O Unprotcctcd Stccl Bldg- 6 O Hcary Timbcr 7OProtcct dWoodER nc TYPE Wood Frarrrc Classcd lA Encloscd Structurc 3 tr Opar Smcturc (No Walls) 4 B Nr SUPPo(cd Structurc 5E Tcnt 6 tr Opcn Platform ( No Roo$ 7 O Undcrground Structurc 9 tr Tlpe of Srructurc Not Class'd AboE TYPE21 SMOKETRA'TRAVELE BY26 I BObjcaofOrigio 2 O Fan of RoodArca of Origin 3 O RoomofOrigin 4{ftc.rarca Conp. of Origin 5 O Floc of Origi! (Multi-floor Bldg) 6 O Strucorcof Origh ? O Bqrcod Structre of Origin FIRE I OObjcaoforigin 2 B Part of RoordArca of Origin 3 O Room of C.igin $dFuc-ratcd ConP- of Otigiu 5 O hoc of Origin (Molti{oor BldS) 6 O Structuc of Origio 7 O Bq/ond SEucttcof Orign AGENTSMOKE t OObjcctoforigis 2 O hrt of Roonr/Aca of Origin 3 ORoomof Odgin 4l$irc-rarcd ComP- of Otigin 5 B Ftoor of Origin (Multi'floor Bldg) 6BStucturcof Odgin 7 O Bclood Strucotc of Origin FIlIvrE I OObjcctof Origin 2 B Part of Roonr/Arcaof Otigin 3 tr Room of Origio 4.XTitc-iatcd ComP of Origin iO Ftoorof Origin (Multi-floo'r Bldg.) 6 O Smrcttrrc of Origin 7B Bcpad Strucouc of Origin t B Har&PirEd Po*tr SupplY Failcd 2 O lrryropcr hsulluion orPlaccrncnt 3BDcfcaircAlarm 4 O Ioadcguatc Maintcoancc $Qancry Uissing or Discooncctcd 6 B Bau.ry DischarScd E O No Alaro Failurc 0 O hilure Undctcrmiocd I B h Room of Odgin/Alcrtcd occ145ts 2 O Not in Room /Atrcttcd OccuPans 3 tr In Room of Origin/Did Not Opcrarc aflNot in Room/Did Not OPcratc 5 O hescnt in Room/Erc Too Srndl 6 tr OpcratcdAlot Eaorin DiscovcrY 7 O Opcrat€d/OccuPaDts Failcd ro Act AIIRM tXnatcryOnly 2BHardwirc OolY 3 OPlug in 4OHardwirew/BancrY 5 O Plugin w/BancrY 6 O Mcchadc.t 7 B Multiph Alarm & PouaSuPPlics AIIRM S{JPPLYz, AITRMTYPE t/(s6s16 2O Hcat 3 O C-ombination Srnokc/ileat 4 O Sprinklcr/watcr Floe/ Alarm 5tr SpccidHazad SP Rctcasc Dcvicc 6 0 Morc Than Orc TPc Prtscnt 7 B Carboo Monoxidc Alarm 8 B No Alarm Prescot I O O6cr T1pc of Ararn Prcsctrt I Os)r@ShrtOfi 2 B i\ht Eroog! ASEot b ConEol Erc 3 g Agcrt Coold Nd l&a.t Fhc 4 O S),stcm Pip,iot Darn.gd 5ONoHc.dshRoooforlin EONoSPFrilurc 0 tl Rcasoo fchilore t Brqctcd t trOpcatod & ContolkdExtingid Erc 2 tr Opcratcd & l,lot CottouExtinS; Firc 3 O Should harcOpcralcdDid Not aBsylstcoPascat/Erc.TooSrmll i E trt{oEqoipil Roooforigin' 0B PcrfmaoaUacPonca NUMBEROF IFYES,WHOWILL INVESTIGATE 3. OSP 4. IrolPDlsh.titr 9' ottrrPcrrodAgc,r. oSFM 2 ooNo IjP Rr&uEsrEx)fivrs ooofi NAMBEROF -5-al*o.-,',-- s2 INTORMATION aj SPECIAL OSHU $f[Jpt3 tf6 rhic trsPoosc ddeycil due to as rcorlliryftlottt!.rlwtfilc8? YES' NO' dcscribe in rcoarks difficulties ALL Juv. #3 Juv. #4Juv. #I Juv-*2 Aec C:cndcr 2O{3-lO(R2000) tuvcnik REIVIARK^S F I RE SW PRE5SI O N EFfORTS COIVTA(ED rO 2' SPRINIS,ERSIISTEM TYPE I OWaPipcSYstcro 2BDryPipcSysrcm 3 O Dclugc Systcut 40 Pp.aciioo SystctD 5OCoEb. DryPiPc &Ple€crioo Slstco 6OrcoOfl SpduldctHcads 7 tr Opco Hcad SystctD, Manual Contml a)$o spdn*lcr Plooaioo O B Troc Sv:. UfflDodcd/t ndctcrtrincd DAIETITIJ31 MEMBER MAKNG RE?tORf,DAIETITI.E'"frt V If YES' plcase SPBAIqFTELD FIRE & LIFE SAFETY GOMPA]IY BU]I BEPOBT FD-{A APP NO CODE ENROUTE RETT'RN TOTAL ADD TOTAL X#PnnsoN: APP NO CODE DIS ENROUTE ARRTVAL rNIN CONTRO RETT'RN TOTAL ADD TOTAL X#PERS APP No 8Jl CODE Drs ARRIVAL CONTROL RETT'RN arNs ADD TOTAL x#PERSON: POIIIT OF DISPATCE! ACTTVITY: APP NO 5 CODE Drs ENROUTE A ARRIVAL Z2 CONTROL RETURNrNs TOTAL ADD TOTAL X#Pensou=ON:' ll.l (I,IINUTES) POIltr OFSl=-POIITT OF DISPAITCE:a{..- 5DIEPATCE: Ll ACTTVITY3 ACTTVITYs ACTTVTTY: EQUTPMENT EQUIPMENT USED:EQUIPMENT USED:EQUIPMBNT USED: TIME PUUPED E WATER SOURctr-r TIME PT'MPED WATER SOURCE--TIME PT'MPED WATER SOURCE_-TIME PU},IPED WATER SOURCE- coo <-k>co oFrZrs--!:1.-d-- ENG SmTkq-fF a n""-* FF CO OFF Dtcrmo.ut CO OFF ENG ENG FF FF ENG FFFF FFr!'!'!'F ON CHIEF gtlI.riI{' Drs ENROT'TE ARRIVAL CONTROL RETT'RN o TOTAL ADD o TOTAL TIWT X#PERSON: -T-(M-rmo- OTHER OFFICERS PRESEMI: CHIEF DIV FIRE DEPUTY T'IRE DEPUTY FIRE T,TARSHAL HAZMAT COORDINATOR EMS COORDTNATOR PIO TRA OTHER OTHER IN RADIO NO CODEDTSPffi ENROI'TEARRIVAL- CONTRO RETURNIN SERVICE TOTAL ADD TIME TOTAL TIl,lE x#PERSON:IEIffiSr TOTAL MANHOT]RS ,1 37 POTNT OF DISPATCE: }{P'' 5 tf ToTAL TIME oF INCTDENT lr z Duplex fire 1530 9th Street 0133 hrs., 3-5-01 941, 831, 851, 859, 803 841 (Fredrickson, McCool, Young) We responded to smoke in a house in the 1500 blk. Of 9th Street. On arrival one neighbor was at the curb and directed us to the fire building (1530 9th ). There was no indication of fire from the outside. The door was open. The occupant then came up to us and stated that he had extinguished the fire with his garden hose. He had burns to his hand and I had 859 check him.He was transported to the hospital for care. We checked for extension and found none. Shew and Wicks arrived and took control of the scene. We returned to Michael Captain Fire Narrative Structure Fire 1530 9th St. 133.?Hrs. a\ 3> 03-05-01 At 1333 hours, 803, 841, 851, & 831 were dispatched to 1333 hours for a possible structure fire. In route, dispatch reported that there was smoke showing and that there possibly were up to 4 children in the structure. At 1338 hours, 841 arrived reporting nothing showing and investigating. 803 arrived and took command at a single-story wood framed structure and reported nothing showing. The structure was an older tri- plex. Upon 803's arrival, 841 reported that the fire was out and that no one was in the structure. 803 disregarded all other responding apparatus except the medic unit and showed the incident under control at 1341 hours. 803 called for an investigator from the Fire Marshals Office. One SPD officer arrived on the scene. An adult male came out to the front of the house from an unknown location. He was complaining of hand burns and had black sooty snot around his nostrils. 859 began treating him immediately and transported him to Mckenzie-Willamette Hospital. The small one bedroom apartment was heavily burned on the cabinets above the stove and in the compact kitchen area with smoke and heat damage throughout. The fire did not appear to extend above the kitchen or living room. 803 had 841's crew check the attic space above the apartment. There was a small amount of smoke but was substantially clear. Investigators were still investigating the fire when crews retumed to quarters. Bruce Hocking Deputy Chief, Operations "A" Shift 03-05-01 I !l'RITE SPACE CIVILIAN CASUALW REPOR OF STATE FIRE MARSHAL FIRE DEPT. ALARM NO. o l- O 21qo1 A aRr S B casuat-rv NAME (r-Asr, FTRST, M0 -.. d 3*l:t*:Fl*. d I'AIE I C casuat-wNUMBER D aes O YEARS tr MOf{IHS FoR INFAMTS OR DATE OF BIRTHMO DAYlt YEAR E mcelgmucrry .DrrgVxre O Buo( tr A$AN O T.IAIITE AMEREAN/ESKI MO OHlsPANlc tr MT.LTIRAOAL tr OTI{ER tr UI\REPORTED F lrru-nnoru o PoucE 0 EMS(NorFD) t(CMUAr.r o oTr#R G oareoFNJURY MO DAY YEAR 3 tl tol TIME()FNJURY totlt3tat H swenrrv O MINOR xtuooeaqrE O SEVERE O LIFETHREATE.IING tr DEADONARRTVAL O DEATI{AFTER ARRvAL I cluseorruuRy f AEcosED To FIRE FLAME HEAT sMo(E oR cAs 2 tr EeosEDTo Toxc FUMES OTHER TT{AI.I sMoIG 3. B EPOSED To FIAZARDoUS MATERIAI-S . . 4. tr JUMPED IN ATIEilPTTo ESCAPE 5. o Fsl_ 6. tr CAIJGHT OR TRAPP@ 7. O STRiJCII,RALCoUIPSE 8. o SrRrrcr( By, CoNTASTwlTH OBrcT 9. O MULTIPLECAUSES 0. tr OnGR CArrs€s Nor LISTEDABoVE J xumenFAcroRS1.[ As-een 2 O IMPAIR@BYALCOHOL 3. tr IMPAIR@ BY OTI{ER CF€MICAL 4. O MENTAIYDISiOVA{TAGED s. o pr+rsceui DIsAo/ANTAGED 6. O PT{YSICAIY RESTRAIT@ 7. tr UMTTEI.IoED PERSoI.I O. B No HUMAI.I FACToRS II$/oL\ED K orren coNTTBUnNG FACToRS: (sE ltANrrAr FOR USrNG) CoMrRrBunNG FAcroR 1: CONTRla,flNG FAcToR Z CoMTRGUTNG FAcToR 3: L acnvrry ar rME oF tNJURy t. O EscAP[.rc Z O RESoIEATTEMPT 3.XFlRECo{rRoL 4. O RETURNEDTOVIONTTYOFFRE 6. o SLe${c 7. O UMBI.EToACT 8. tr IRRAIIOI.IALACTI T,I 9. tr A TMTYATTIME OF INJ. NoTcI-AsSEDAEovE O. B ACIMTYATIMEoF IIU. I,NDET. oR !.IoT REPORIED Ml arnre srART oF THE tNctDENT, TI{IS CASUALWWAS: IN TTG AREA oF oRIGIN IISJoL\ED IN STARTII{G INCIDENT M2 ATTHEIMEoFINJURY, THlscAStALwwAs: lN THEAREA oF oRrcrN IN BT,ILDI,.G. I.IoT IN AREA OUTSIOE (rF oursrDE, co ro N) YES)4 YESJ( NOo NO0 YESX YES g YES O NOB NOo NOo M3 rloon ar nME oF INJURY, ooiIPI.EIE F ITIJT,RY occ{,RRED INSIDE: rltFLOOR AT START oF It'IoDEt.IT BELovl/GRADE tr FLooRATTIME OF INJURY, I I IF DIFFERENT BELOA/GRADE O M4 specrerc Loc rroil ATTale oF triuuRY, lF htoT AREA oF oRlGtN N HaruReorNJURv Gl. B ASfl{rxriVSMotGOt{-y 60.4 BURNS & AsprfixWSMoKE 07. B'B(RNSOr{Ly 31. tr Wout\D, Cur, BLEDtr.rG 21. O DlSLocAIol.l 40. O CoII|PI.AINToF PAIN. IT.ELIJoEDARE HTARTATTAo<S AT.IDSTRol<Es 48. O SHoq( AMpFm-AcIc 49. o Sl{ocl( ELEcTRtcAL 51. O STRAIN, SPRAIN O NATTRE OF INJURY oR ILLNESS NoT cLAsS@ ABovE I I I (ENTER CooE FRoM MANTJAT tF tNJrrRy r.lor LtsrED ABovE) OO. O NAruRE OF INJURY oR ILLNESS UNDETERMINED oR NoT REPoRTED O panrorBoDyINJURED 10. tr HEAD RESPIMTORY SYSTEM AND HEART 71. o Munfl€pARTS 99. O PARTOFBOOYINJUREDNOT CLASSEDABo/E OO. O PART OF BOOY INJIJRED UNDEIERMINED OR NOT REPORIED 21. tr NEc( 29. tr B@y.TRtnKBAo( 30. tr ARH 40. O LEG as..\ xaruo 45. O Foor 50. O INIERML IT{CLUoEDARE P rnearueuToFcAsuAlwt. .1Kro rulseoer ro EMERG. cARE FrcIUTY 2. O NoN-FDTRAI.SPoRTToEMERG. CARE FACIUTY 3. o NoN.FDTRA,.ISPoRT(WIHFD srAFF) To EMRG. cARe FActury 4. O TRANSPORTToT\0T.I€MERG.CARE FAclLITY 5. O TRANSPORTTOMORGUEOR FUNERAL }{oME 6. O TRANSPORTTOPRIVATERESID€NCE 8. tr NOTTRAAISPORTED 9. O AID REFTJSED G-2196) MEMEER TITLE U4€,n DATEd30jol TtrLE I DATEADcrnoitAl ryDRirATtortEY