HomeMy WebLinkAboutPermit Fire Damage Report 2000-11-21\CrIY OF SPRING ILD
Fire & Life Safety
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DATE:/ -oa
FIRE DAI'iAGE REPORT
OR
ELECTRICAL HAZARD
TO:
FR0r"1:
SUBJECT
Bujlding DePartment
Springfield Fire DePartnent
Structura'l Damage to Bui I di ng
Address or I ocat'ion of bui 1di ng 3r /tr a sl,
Name of ouner fnn
Type of building ,) ln.^r.Y,
(Dwel1ing, Store, I^lar ehouse, etc. )
*oEstimated value of building
Estimated loss to building cOt
Date of fire / -oo
Location of damage in building ,(/2 /*/ c ),<-u1/
(Roof, l,lall, Exterior' Inte rior, etc. )
Structural weakness as a result of the fire F
(Burned rafters, Beams, Jo ists, etc. )
Additional pertinent information
Electrical Hazard /tr,... e r r-Jo.- r* )* rllo A4,,ttz /!
(Wirinq,0ut'let , etc. )
cc
o
Signed
,t, ^J,
STA7E c0
COMPLETE FOR ALL INCIDENTS
trArE ., trNeurlxcroei.rr
BGTANGETo
2000
t-ll
nrsnomruc,$pl jjgfigfu_fiag_DISTRICTOF DEPT.cornrrr Lanq
I AL/IRMDATEt/ -al-oa AI^AR}TTIMEel t1 DAYOFwrrx.AU AR,RIVALDATE ARRIIYALTIME2.t >- r
oeraracx(IN-
28 OTIIERTYPEOF
SM'AIIONPRIMARY2AOFTYPE FOI]ND:bfirc aot r thc €f,(lf.&rolv.4 fc)ti".
2C OTIIER TYPE OF SITUATTON FIOUND:
'tiddl:_Fi.ld?:-:fidd3:4:Frdd5:Frld 6:
_?3 ( tVr:S1
3 INCIDENTADDRESS
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"
AP CENSUSTRACT
3c(S/2, * 3
DISTRICT/
ZONE
I ,5UIINI55 N.IMI
/e,t /e-/a-sy
DOA
atq?
TEI.EPHONE
'cyt' 7?q -
Prd ek
IXeUe@frn frfl5 BUStr{ESSOWNER
1/ Lk
DOB TELEPHONE
()
BUSINESS
7 PROPERTY MD DOB
ZP
TELEPHONE
()
t BUIIJINGA.IOBIIJ PROPERTY OT,VNER EOONTSS-ZIP
'sq (' - r?-) roo
TELEPTIONEREPORIEDBY g:5(
-)t"6oct )4
IO INCIDENT BYADDRESS
9 MD DOA
?5t tVu {,17 q77Z'P
II
'OFFIREPERSONNELRESFONDINCc"*- /a-"ln"r,*"r, .d 'OFEIIGINESRESPONDII{C,L 1
TOF AERIAL APPARATUS
RESPONDING
, OFOIIERFIRESERVICE
^ VEIIICI.ESRESFONDINGJ-ol NONE
MUTUALAID
I O GI\IEN
20 RECETVED
3Z$rciblcEntry ?l,Sntcsligaa 360TraospurLffExtingrrish 3l trRcsqrc 42tj11*nntlD16trVcotilatc 320Extricatc 4I trRcmoveHazard
47trDcconArca
46 tr Dccon PcoplerEquip
45 trMooitorHazmat
43 trEvacuatc
35 tr Scarctr
53 trStandby
52 BMovc Up
34 tr Pnovidc Personncl
74 0 Canoclcd at Scenc
72 tr Canccled Euoute
t2 TTPEOF (CHECKAII,
14tr 33 trEMS SafeArea tr
roR
\1
7 tr Watcr Frrom Tankcr/Tcodcr Shufle
8 tr Crlound Crcws W Equip Atd/Or Air Support
Ut PRIMARY OF
5 tr Warcr Caried Oo Initial Apparaos
3
4 tr Autornatic Extiogrishing SSnstcm
Fron NotGassificd
f trSdf-Eldoguishcd
2 A lvftkcshiftAicls
13 ONonc
la OF
ro
MODEL TAIL'M STATE"/
DdWarcronty
Dirt
3 trClassAExtiog
Qass B/C
5 tr Class A/B/CExting 7 B @2
6OClsss D I trHalon
9 tr Coryrcsscd AirFoam I I g Ctsss B FoaD/AFFF
Yy'/ Watcr102
Aed
OF EQUIPMENT INVOLVED D{ ICNrrlON GoqtcaljeE)
E YEAR MAKE MODEL SERTALf POWERSOT.,RCE IOTDGD
2OPOR[ii3I.E17 IGNITIONFACTOR
lt ET'MANFACTORS
TNYOLVEDIN
IGMITON
Alccp
o
t trM.lc
2EtuDah
Uocoscious
o h{Agc.ldcca.rcrb rnrtaitc*(A8c65+) tr
Pcrsou
B
o Pfu.ic.Xy
O&aavrmecd tr
Mulbh Fccoos
Imh/Ed tr
19 FORM OFIIEATOT TCXMOT MATERIAL FIRST IGMTED WAS MADE Or.ITEM FIRSTIGNTTED
20 I.EVELOFFIRE
ORICIN I trEclcwc{ouod l(c*rar.*r 3 OAborcGurod 4 O I! Hidr Ftor of Origio
(SmctrrctsOalv)2I ESTIMATED
VALT'E _ Boildio8( soo .00
- Cooas4 5oo .@
Mobib Prop<tyedCoucos
.00
OdE
.@ .00
(Tto.
LOSS ft 5loo .oo
e Soa .oo .o0 .@
d/OOo .@
ficfaAarySrsaaa:)
ROOFCOVERINC
t O Class A Or B (Non Combustibh; Maal, Tile, C-omposition)
?dcass C Comp{rdtioo or Prcparcd, Mat'l 14*6"1, thinglcs)
3 tr (xass C (trcatcd rnd Listcd Wood Shinglcs) '. -:-
48 Unutatcd Wood Shioglcs
5 ONonratcd Roof Cosiog(C-anvaq Plasdc' HotTar)
8 tr Structurc Wthout Roof
9 D RoofNot Classcd Abovc
@rsrR(rcrroNTt?E
t trStd &Concrac,3aI{r
2 B Piotood llamoryE a. & Wood hL
3 OUogotcctcd lvlasooryE ct. &Wood InL
atrPotcctcd SadBldg
SOt ryoccads&clBld&
6OHcavyTidcr
}(nmtcodwooaeamc
8B t nprctccied wood Frarnc
9OTmcNotClassod Abotrc
2' STRUCTT'RETYPE
lEEnctosod Stnrcnrrc
3 tr Opca Smuctuc (1.&o Walls)
4tr AirSupponcd Smraurc
5E Tcot
6tr OparPladorm(NoRoo!
7O UndcrgroundStruaurc
9 B Tlpc of Struaurc Not Class'd aborc
PRTMARY AVET{I,E OFSMOKE TRAVEL25 PRIMARY FACTOR CONTRTBUTING TO FL/\ME TRAVEL
FIRE SUPP&ESSIOTY EFFO&$ CONFINEIT TOffTENT OF DAMAGE CA,ASED BT26
I trObjcaofOrigin
2 O krt of RoodArca of Origin
3 O Room of Origia
4 B lirc.ratcd Comp- of Origin
5 O Floor of Origia (Multi-floor Bldg)
6 O Structurcof Origin
FIRE
Stucartcof Origin
ofThis
guol(E
I OObjeaofOtigitr
2 tr hrt of RoosrrAca of Odgin
3 O Rooru of Otigin
4 O Erc-iatod Comp- ofOrigin
5 tr Floor of Origio (Mutti-floor Bldg)
d6lr6!ffir/ofoigin
l.E@qond Sttucorc of Origin
9 O No Damage of This Tvpc
EXffING(,ISHINGAGE}iT
I DObjcctoforigin
2 O Pan ofRoon/Area oforigin
3 tr Room of C.igin
4 O Frrc-ratcd Crmp. of Origin
5 tr Floor of Origin (Molti-floor Bldg)
6 dSu-ucorc of Origia
7l3cyond Structnrc of Origin
9 O No Damagc of This Ty?c
FIIME
I tl Objcctoforigin
2 O Partof Rodr/Arcaof Origin
3 tr Rooq of Origin
4tr Finc-ntcd Corop. of Origin
5 tr Floor of Otigin (Multi-floor Bldg:)
$t$rocucof Origln
{ltscyoad Struaurc of Origiu
8 B Non-firc Damaec RcDort
REISOII FOR AI.ARM FAILUR.E
I O l{ardwired Por,tt Supply Failcd
2 O Lnpropcr Insullatioo or Placcrncnr
3BDcfcaircAlarn
4 B Inadcqualc Maintcoane
5 B Bancry Missing or Disconncsrcd
6 OBacc(,wDtschrrgcd
8 trNo Alarm Pailure
0O lhiturcUadacrmiacd
AIARM PERFORIT{ANCE
I B In Room of Odgir/Alcncd ocaqPac
2 O Not in Room /Alcrtcd OccuPans
3 O kr Room of OrigiolDid Not Opcratc
4 B Not in Rooro/Did Not OPcratc
5 tr Ptcscntio Rooro/FircToo Small
6 BOpcratcd {otFaaorin DiscouY
7 O Opcatcd/Occupants Eailcd to Act
AI.ARMPOWERSUPPLY
I O BattcryOnly
2O HardwircOnly
3 BPlugin
4 O Hardwirc VBaccry
5 O Plugin w/Baucry
6tr Mccltanicrl
7B MultiplcAlarm & PourcrSupplics
r, AI.ARMTYPE
I O Smoke
2OHat
3 B Conrbination Smokc/Ilcat
4 O SprinklcrAt/atcr FIow Alarm
5 tr Spccid ll2zad S1rs Rclcasc Dcvicc
6 0 Morc Than Orrc T12c Prcscnt
7 tr Carboo Monoxidc Alarm
&Q.Io Alarm prcscnt
9 tr'O&crTypc of Alarn Prccrit
0 O AlarrD Unfxtoum/notrcponcd
REASOT{ FOR SPRINIq,ER, FAIII'RE
I Os).stcmsbutOff
2 O i{ot Enrrngh Ageat to Control Erc
3 BAtEotCould Notlka.:h FirE
4 B Sy:i.o Piping Damg€d
5 O No Hcads h Rooo of Origin
SONo516&0Rilure
0 O Rcasoo forFailurcuucPctcd
SPRINKLER PERFORII{,TNCE
I BOpqatcd &Corrtrolhd/Exting'd Fire
2 B Opcratcd & Not €ontoUExtiag. Firc
3 tr Should harrc OpcraadDid Not
4 O Sptcm Prcscnt/FcToo Srnall
8 O No Equip ia Room of Origin
OB HosaanccUarportcd
NUMBER, OF EET.DS OPENED2t SPRINKERS1STEMTYPE
I BWaPipeSystcttt
2UDryPipc Sy*ao
30DdugeS,4stcm
4O Prrc-aaioa Systcrn
5OComb- DryPipc a Praaaioa SY*co
6 B rOn4tr SpdnldcrHcads
7 tr Opco Hcad S)'stct!, Manual ConEol
e)/xo sprintta Prooaioa
O E Tlpc Sys. Uorcpodcdttndacilftte{
FOR
t. osFM I-oc.I
OF .66
3. OSP 4. Irc.lPDEDcdf 9' O6crPctsolAe4,IFfES,WEOTYILL
INYESTIGAIE
D
REQT'ESIED otrNo ldtzs
FIRESERVICE ,61 NUMBEROF
IN]T]RIES
-CO
flII.E
Zu.Dy'*,'n
3I MEMBER
MAXING
REPTORT 1f,2/za-I DAIErrII.E /&IADDMONAL
INFORMATION
BY
NAME v
33 SPECIAL OSFM STT DY: Itas 6brcsponse ddaycd due to access .lifficulties resiltiqg from rarrov sfutcts?
Juv. #4Juv. #l luv.*2 Juv. #3
Age
Crender
2O{}rO(RZ)00)
lwcaikilFtrc
?O roo.ooo-49.oosQrr
,opoo-99199SQFr
iuremrks
RENIARKS
STATE OF ORrcON OFFTC
2IXIO OREGON AI-L INCXDENT ffiffi#[\
trNrrrrlr*cpelrr
II
5
INCIDEhITS
r1t
LaneCOT'NTY DEPT.
DAYOF U TN
FOUND: Gf r nrc b &ndnd atcrric t
".
of fir)2A PREVIARYTfPEOF
2C OTHER FOUND:
Frcld2:''..Iicld5:Eield 6:
3 INCIDENTADDRESS
,5 b qa7 €ENSUSTRr'CT IDISTRICT/
ZONE
(Irs. Err.MI)
-)t-o t a yq-eroo
G:st,Errl'MD5 ()
7
G
OWNERNAME(Isr,
-;/ -6 0 aLl - aSoe
TELEPHONE
(
2s /6 ADDRESSt!- sl 1
9 INCIDENTREPORTEI)
4/ c-t h 2-al-€O
DOB
(?g@
?S/
ADDRESStBYU r7ztP
Cerccr
II f OFflRE
RESPONDTNC,_
,OF
RESPONDING
IOr. OTIIERFIRESERVICE
,1 VEETCIJSRESPONDTNG o{ rom
AID
I O GI\IEN
3@ForciblcEotry ?l-E{qrrcsrigac 36trTransport
I5.€lQniaguish 3l ORcsolc 42tr1:l"z,r,*.ID
16OVcotilate 320Eoicatc 4ltrRccptcHazard
4TODcconArca
46 BDecon Pcople@uip
45 O Monitor Haanat
35 OScarch
53 El Standby
52OMovcUp
34O PrrovidcPcrsonncl
T4OCanccld atSceoe
72 tr CancelcdEnroute
l.:l TTPE
43 Evacrratc
(CHECKALLTHAT
33 BEMS SafcArca D
FORALLFIRES
t7o
?s
8 B Crroud Crews W Equip And(k Air Support
t3 OF
5 0 WatcrCarricd Oo IDiriaI Apparans
9 trMahod Not Gassificd
4 tr AutomaticExtinguishing Systcm
DraftOr
f 0sdf-E.:dryuishcd
2trMakcshiftAids
13trNone4tr
S/J
AGENTOF
tsE
<-<-
Ddwrs Ouly 3trClassAE:ciag.tr5 Oass 7 tr g2
6 DCtass
9 tr enp,rcsscd Atu Foam I I tr Class B f.oaEi/AITFF
lOtr Class A Foam W/Watc(
15
2
M YEAR 'MAIG
MODEL SERHLil/AIRCRAFTTAIL'UCENSE*STATE
15 ROOM/AREA OE rmr-onlcnt
</ ,/-)h e-a
EQUIPMENT INVOLVED IN IGMIION (Co,qlac I to D
E YEAR MAKE MODEL SERIAL*POWERSOI,.,RCE IOFDGD
2IIPORTABLE
?, i e<--* Flt*,*-, - C-^ /*-t17 IGNTIIONFACTOR
oru ft4 pex-f D*a.t8 EU&rNFACroRs
INVOLVEDIN
IGMTTON
Artc.p
tr
t OMJc
2BFcoh
Urcoasciors
CI
UnncadcdFaso
0
,urtoilc O
Put Agc and Gcrd6iE
REMARKS
Nrrobcrof
Jmilcs:
EUcrly
(,!e6ti) O
Itrylic.f,
OBaanuged tr
Mutiplc Fctsor
I!rcltrcd tr
19 FORMOFEEATOFIGNMON
F/.+n"
MATERHI, FIRSTIGMTED WAS MA.DE OF
U--b,- d 5 r Uing
ITEI},I FIRSTTGNTTED
20 LEVELOFFIRE
ORIGIN t OBcbrGuEd zEEr.rraf.*r 3 EAborcGruod 4 trIoF[snr Ftu ofOrigia
(Suucturc Fis Oolv)ZI ESTIMAIED
VALt,E d
.00
EuildirySoo .@
tcy@:aco Mobilc Ptopaty aad Coolcc
.@
OdE
.@
,TOTAI-€qrc .@z2
LOSS 2oo .oo
d d 5o .rx).@ .@
(4-so .oo
.{o.E
Sbaeq
MOBrr.E PROPEXTIY INVOLVE) (Coqte rrc M)
2' A?TROXIMATE
8UU-D!NG A'GE (lr Y6)2a
aUrLuIrlC SIZE (Groud no'aody)
rXo-scasarr
3oJo(x)-9999SQFT
4tr ro,00o- 19.999sQFT
6trrqm.99p99QFr
?o roqooo-49.mosQFT
5tr FTo
@Tl[sIRUCIrcNTYPE
t Ostccl &Omcrac,3a llr
2 O Protcod lv{ury Ext & Wood IDt
3 Ouaponcctcd lvtasooryExl & Wood InL
a O Eotcc'tcd. Stcd Bldg-
5 O Unp,mtcacd StEl Bldg.
6 O Hcary Tirnbcr
)deror"tawooafran
8 O Uaprotcacd Wood Framc
9OTvpcNotClassod Aborc
\oorcovERING . i;,
ltfCbss A Or B (Non Combustiblc; Mctal, Trlc Compo6ition)
2O Oass C CompositioorPrcparc4 Mat't 6*6"1, thinglcs)
3 O Ctass C (frcatcd a$d Lislcd Wood Shingl,cs) .-+--
4B Umratcd Wood Shinglcs {'
5 tr Nonrarcd Roof Corcdng ( Caov:s, Plastic, Hor Tar )
8 B SrructurcMthout Roof
9 B RoofNot Classcd Abovc
2' STRUCTT'RETYPE
td-eoa*"as*..r"
3 tr Open Strucnrrc (No walls)
4 O Air Supportcd Strucnrrc
5tr Tcnt
6 tr Opctr Plat'orm ( No Roofl
7 E Undaground Structutc
9 B Type of Structurc Not Clnss'd Aborc
PRTMARY AVEI{['E OF SMOKE TRAVEL25 PRIMARY FACTOR CONTRIBUTING TO FI./TME TRAVEL
Con^bc,s fr'b h 1il*tqtx /t
FIRE SAPPRESSTON EFFORTS CONFINED TOEXTENT OF DAMAGE CAASED EY25
FIRECONTROL
I BObjcaofOrigin
2 tr Part ofRoor/Area ofOrigin
3 O Room of Origin
4 O Frr!-ratcd Comp- of Origin
5 O Floor of Origio (Multi-floor Bldg)
6 O Structurc of Origin
7sbepnd Snucturc of Origin
9 O No Damagc of This Typc
s]\toKE
I BObjcctofOrigin
2 B Part ofRoonr/Area ofOrigin
3 ORoom of Origin
4B Fre-ratd Comp. of Origin
5 O Floor of Origin (Multi-floor Bldg)
6 O Strucrurc ofOrigin
7}Gcyond Structurc of Origin
9O No Damasc ofThis Typc
E'ffINGUISEINGAGE}iIT
t OObjcctofOrigin
2 tr Part of RoordArcaof Gigin
3 tr Room ofc.igin
4 O Ere-ratcd Comp. oforigin
5 O Floc of Origin (Multi-floor Bldg)
6 O Sructurc of Origio
TEBqr,ond Smctorc of Origin
9 O No DamaseofThis Trpc
FI,AME
I trObjcctof Origin
2O Partof Roon/tutaof Otigin
3 B Room of Origin
4 B Firc-ratcd Comp. of Origin
5 tr Floorof Otigin (Multi-floorBldg.)
6 O Structurc ofOrigin
fiBcyond Sructurc of Origin
8 O Non-firc Damage Rcpon
REASON FOR AI,A.RM FAILURE
I O Hard*ircd PowcrSupply Faild
2 O Impopcr hst-llation or Placcrnent
3BDefcaircAlarm
4 D hadcquatc Maintcnancc
5 B BaltcryMissing orDisconncctcd
6BBad6yDitcharyod
8 O No Alarm Failtrc
0 B&iturc Uodctcrmfurcd
AITRIVI PERFORIT&TNCE
I O kr Room of Otigin/Alatcd occupa!6
2 B Not in Room /Alcrtcd Occupants
3 O In Room of Odgir/Did Nor Opcratc
4 O Not in RoorarDidNo(Opcrac
5 tr Prscnt il Rooo/Hrc Too Small
6 OOpcrdcdfi.lot Faaorin Discotrcry
7 O Opcratcd/Ocrup.ats hilcd ro Act
z, AIARMTYPE
1 B Smoke
2 D Hcat
3 B Combination Smokcy'llcat
4 tr SprinklcrA/{ater Flow Alarm
5 tr Spccid Hazatd Sp Rdcasc Dcvicc
6 O Morc Than Onc Tlpc Prcscnr
7 tr Carboa MonoxideAtarm
fiNorurrrnpro.t
9 tr OtbcrTlpc of Alarm PrEscflt
O O Alarm Unknowa/not rcponcd
ATJRMPOWERSUPPLY
I OBancryOnly
2 B Hardwire Only
3 O Plug in
4OHardwircVBattcry
5OPluginw/Baacry
6 O Mcchanical
7 O Multiplc Alarm & PorrcrSupplics
REASON FOR SPRINIG,ER FAILI'RE
I tlS),stcmShutOtr
2Oi{orEooogn Agcotto ConEol ErE
3 B Ageat Coold Not Rcach Erc
aO SFtco Piping Oaoaeed
5 O No Hcads h Room of Origin
SONoS5a*eoRilurc
0 O Rcasoo for Failurc Uotcponcd
SPRINKLERPERTORMANCE
I B Opqatod & CoatolkdFxtingid Et€
2 tr Opcratcd &NdOoaaoUExting. Erc
3 tr Slrould harc Opcrarcd/ Ditl Not
4 B Sptco Prcscat/frcToo Sraall
8 tr No Eqoip iaRoomofOtigin
O O Pcrformamc Uacportcd
NI'MBER OF EEADS OPBiIED2t *RINIC,ERSY'ISIEI}T TYPE
I trWaPipcsystcm
20DryPipcsFt to
3 tr DclugeSystcur
4 O Prc-acrioo S)4icrB
5 O Comb. Dry Pipc & Peaaion Sptco
6 O'Oa.Of Spdotdct llcads
7 tr Opco Hcad SlistcsD, Mattual Cootol
bENo Sp,tinklcr Pmtccrion
6 O fw Srs. Uarcoortcarundctcrahcd
FOR
REIVTARILS
IFYES,WHOWILL
II{VESTIGATA
3. OSP 4. LocellDlSbaitr 9' O6crFcrsoolAscosyl. OSFM
Narc
rfrcs- TOIJI}W UP II{VESTICATION
REQIJEST€D OENO
I FIRESERYICE6l .aNAMBEROF
FATALINES
O'IHER I9 NUMBEROF
IN]TJRIES
FIRESERVICE .q
/ -2/ -oaDATETITLE
TITI.iE
3I }IEMBER
MAKINC
REPORT
,.ADDIrIONAL
IITIFORMAIION
ET
NAME
33 SPECLIL OSFM SruDY:Was tiisrtspousc itdayed due to s66gss.lifficultics re$ttirg froularorr stnects? YES.
describc iu rerrarksIf YES, please
luv.{2 Juv. #3 Juv. #4'Juv. #l
Age
Gender
2O{}rO(R2(}00)
twcnik */'Ftrc
Otot tacldog B.r.{-.d
Loc.tED
I
STATE OF ORrc<'N OFrrc
2OMOREGONAIJ c 0
ALLINCIDENTS
1
DEpr. REspoNDrxc_Spfj-Ogtie]d_llite__DISTRICT corrNTv Lane
I AI.ARIT'DATE//-2/ -oo DAYOF_.
wggr. / (J AR,RIVAIDATE ARRIYAITIME)ts-l oersreq(Ir{IN
2^ PRIMARY TYPE OF SITUATION Qf r fia & hrlvcd, o&rrh gpc o( l.re)
28 OTHERTYPEOF
2C OTTIER TYPE OF SITUATION FOUND:
STIIDIES 1:Fi.rd 2:'. Fi{d5:Frld4:Frld6:
3 INCIDENTADDRESS5: t tYu S;/,?tqz>
UP CENSUS TRACT31 ,*JDISTRICT/
ZONE
4 OCCUPANT NAME (ks( Ersr. MI) 6 COMPANY/BITSINESS NAME
?erQ-<Slnn /-,5€-..,\ .
DOB
t)-/2-sq ) I r?-ot {1TELEPEONE
(
5 BITSINESSOWNER NAMEC -<r, E6( MI)DOB
6 BUSINESS OWNER A.DDRESS zLP
7 BUILDING^iOBrI F pROpERI-y OWNER NAME (t -.{i Frst tvg)
Ru4. k , (),c-/<
DOB TEIJPHONE
(
E Blrrr-DrNcnfrosuj rnofrnry oruvrn loonrss ?*-i* .r42.
zf,P
9 INCIDENTREPORTED ({:s( Er.(
t- 60
/ Y* S/,dJ
DOB
/c
BYADDRESS
qq -?700
1z qzz
()
RESPONDINGc.*7i-'itrJ-o, 6
It SOFFIREPERSONNEL
2
rOFEI{GINES
RESPONDING '
OF AER.IAI APPARATUS
,*
* OF OTIIERFIRESERYICE
dErlrra
F( RESPoNDTNC o{ Nor.re
MUTUALAID
r O GIVEN
20 RECETVED
lT6norciUtcfory
ISpExtiaguish
16 tr Veotilatc
3l ORcsorc
32 trExtricate
33 oEMS
36trTnnsport
42Oll@..ID
4l trRcoorcHazard
4TODccon Area
46 tr Deoon PcoplclEquip
45 B Monitor Ha::mat
43 DEvacuarc
35 BSearch
53 O Standby
52 O Movc Up
34 tr Povide Persoonct
T4trCanelcd atSlccoe
72 BCancclcdEuoute
TAIGI{(CI{ECI(A.L
7l2(nvcstigate
&ca
TELEPHONE
tll
?3
7 tr Water From Tankcr/Tcudcr Shuule
8 O Ground Crcws W Equip And/OrAirSupport
OF
5tr Caricd Oo Initid Apparanrs
3 Abovc
4 tr AuooaticExtinguishing Systcm
DraftOr
Esclf-Erisguishcd
2trMakcshiftAids
Q4WatcrOoly 3trClassABdin& strCtassA/BrcBciog 7B@2 gtrConp,rcsscdAirFoam lt OClassBFoadAFFF 13BNoae2trDirt 4OCla$B/CEriog 6trOassDExling. 8trHaloo l0trCXassAFoarn l20lVcciugAgpotWWatc( I4trOther
r'I PRIMAN,Y AGENT OF ETTU{GUISEi,GNT
15 SPECMCPR,OPERTTUSE
fres,J.o^. -MOAIL.E PROPERIT IIWOLVED (Coqle E* M)GENER.TLPROPEKTYUSE
M YETR MAKE MODEL SERI,AL flAIRCRAFT TAIL il UCENSEI STATE
T6 R(X)M/AREA OF FIRE ORIGIN
//
EQUIPMEI{T IWOLYED IN IGMTION (C@plc.c UE D
E YEAR MAKE MODEL SERIALI POWERSOIJRCE IT'FD(ED
2OFORTABI.E
ZEJ;',+^/ r/.*1 {zot^ S/J fi).17 IGNIflONFACTOR
It EI'MANFACTORS
I}WOLVEDIN
IGMTION
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REMARKS
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Inohred tr
F ,-e J
19 FORI}' OF HEAT OF IGMIION MATERIAL FTRSTIGNTTED WAS MA.DEOF
/--'aoJ
ITEM FIRST IGNITED
5)Jrha
2.0 IJVEL OF FIRE
ORIGIN
t trBclowGdld 2 trCrorodrrrct 3 BetorcCrqroa 4 B ID Frieh Floor of Gigin
(Srucrw Ere Oolv)2I ESTTMATED
VALI'E
BuildilSt 7oorn.*2o 0o6 .*
Codaaa6 Mobib Propcqy erd Gooros.6.*06(
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- TCTTAI-6 t-n .jo.1 .@
ZZ ESTIMATED
LOSS /M.@4 B'.*.d .00 .@ /. ooo .oo
d
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AP
BOthcr_
()
BUIITING SIrZE (Gmd Flo( dy)
Ido-scasaFr
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40 ro.oqr- 19,999sQ
5tr
FOR ALL
REMARKS
6o ,0.@0- 99199SQ Fr
?tr roo.ooo-49.mosQFT
FTOR
FT
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,l:I APPROXIMATE
AUU.DTNG ,(GE crY6)3o
24 STRUCTT'RETYPE
lE radoccd Structurc
3 tr Opca Suucture (No Wdls)
4 B Air Supportod Structurc
5tr Tcot
6B OpcoPladorm(NoRoofl
7 O Undcrground Stnrcturc
9 tr Typc of Struaurc Not Cass'd euor
@I.ISTRUCIIOI{TYPE
I OScd & Coocrctc,},41Ir
2 B Protccrcd Masonry Er. & Wood ht
3 OUnprotcctcd MasoaryExL & Wood InL
4 O kotcacd Stccl Bldg.
5 O Unprotcctcd Stccl Bldg.
6 O tlcary Timbcr
)El.Prrotcctcd wood Erarnc
8 O Unprotcacd Wood karnc
9 OTypc NotClasscd Abovc
I t O O"ss e Or A (Non Combustible; Mcral, Tlrk, @gpr6s;66"1
I a6CUss C Comgosition or Plcparcd, Mar't 6sr6"1, thinglcs)
3 O CXass C Grcad and List d Wood Shiaglcs) ::r
4 O Unmatcd Wood Sbinglcs
5 O Nonratcd Roofc.ovcring ( Canval Plastic, HotTar-)
8 O Structurc Mthout Roof
9 O Roof Not Oas-scd Abovc
ROOFCOVERING
25 PRIMARY FACTOR CONTRIBUTINC TO FIJ\ME TRA\IEL
P,4./r;4 /o*d',4zr,4.slZ/r. r
PRIMARY AVE}TI,'E OFSMOKE TRAVEL
EXTENT OF DANACE CAASED BY26 F IRE SAPPRf5.SION EFFORTS CONFINED TO
FIRECONTROL
I OObjccrofOrigin
2 O Pan of Roogr/ArEaof Origin
3 O Room of Origin
4 O Erc-ratcd Comp- of Origia
5 O Floor of Origio (Mutti-floor Bldg)
6 0 Structure of Otigin
?EBqrcDd Structre of Odgio
9 B No Daroage of This Tvlc
FI,AIVTE
I O Objcct of Origin
2 O Part of Roon/Area of Origin
3 B Room of Origio
4 B lirc-ratcd C.omp. ofOrigin
5 O Floor of Origin (Multi-floor Bldg.)
6 O Structurc of Origin
TEBryond Struaurc of Origin
8O Non-firc Danusc RcDort
SII'OKE
t OObjcctofOrigin
2 O hrt of Room/Arca of Odgin
3 ORoom of Origin
4 O Ere-ratcd Gonp. of Odgin
5 OFloorof Origin (Multi-floor Bldg)
6 B Strucrurc of Origin
?SBcfpnd Ssucturc of Origin
9 O No DamaecofThisTypc
EI(TINGUISHING AGEI.IT
r OObjcaof Origis
2 B Fart ofRoon/Area ofOdgin
3 B Room of C.igin
4 O Frrc-ratcd Comp of Otigin
5 O Floor of Origin (Mutti-floor BIdg)
6 O Structu. of Origin
?gBcyond Strucdrc of Origin
9 O No Damaee ofThis Trpc
REISON FOR AI.AR}T FAILURE
I B Hardwted Pows Supply Failcd
2 O lmpropct Irstatlation orPlacerncnt
3 BDcfcaiveAlarm
4 B Inadcquatc Maintcoanoc
5 O Battcry Missing or Discooncctcd
6 O BatEryDischargcd
E O No Alero Failurc
0 O hilurc Undctcrmincd
AI.ARIUPOWERSUPPLY
I ABattcryOdy
2 O Hardwirc Only
3 O Plugin
4BHardwircVBaacry
5 O Plug in w/ Baacry
6 O Mcch.nical
7 O Multiph Alarm & PourcrSupplics
AI.ARM PERTORIVI.ANCE
I O kt Room of Origir/Alcncd ocopus
2 O Not in Room /Alcncd Occupans
3 O In Roomof Origir/Did Not Opcratc
4 O Not in Rooro/Did Not Opcratc
5 O Prcscntin Roorn/ErcToo Snull
6 O Opcratcd/Not Ector in Discovcry
7 O Opqatcd/Octupants Failcd Io Acr
z7 AL.ARIITTYPE
l BSmokc
2O Hcat
3 O Combioation Smokc/llcat
4 tr SpriaklcrAilatcr Flow Alarm
5 B Spccid llazad Sys Rclcasc Devicc
6 B MorcThan OncTlgckescnt
7 O Carboo Monoxidc Alarm
8bNo Alarm prtscar
9 O O6crT]"c of Narm Prescnt
0 g Alarrn Unloowu/mt reponcd
SPRINKLER PERFORI\{ANCE
f O Opcratcd & ControUcd/Exting'd Frrc
2 O Opcratcd & Not CootrouErtirg. Hre
3 O Shoold havc OpcrarcdDd Not
4 O Sptco Prcsca/Erc Too Srnall
8 tr No Equip ia Room of Origin
0 O Horrnancc Ualtportca
REASON FOR SPRIT,KI,ER FAILT,RE
I O Systaa Shut Off
2 O Not EDooS! Ageot !o C-oatrol Ere
3 g ASEat Could Not Rcach Fue
4 O S)4stco Piping DanaSed
5ONo Hcads Ia Roomof Origin
8 O No Syrrcra Failurc
0 O Rcason forFarllurcUnrcpctcd
NUMBER, OF EEA.DS OPENEDI 2S SPRINISTRSY'':STEV{TYPE
I t owctnp.sp-rt
l2ODryPipcSyscm
3 trDclugcsysm
48 hc-aaioa Systccn
5OComb. DryPipc & Preaaion SPcrn
6 O rco€fl SptinldcrHcads
7 tr Opco Hcad Syst sE, Manud Control
8!No Sprinklcr Protcaioo
O B Trpc Strs. Uucportcd/IJndctcnrincd
3. OSP 4. LocelPDrSbaitr 9. OtcrPcaoolAFoc,y
- /i..Pdl.EYES
, FIOLLOW T'P INYESIIGATION
REQTTESIED OOIiO
NAUBEROF -FXTALTTTES @ FIRESERVICE .d *gfi NT'MBEROF
IN]TJRIES
rrresenucE p-oTAER I
//?/-*/1* 2 / *ooDATE31 MEMBER
MAISNG
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