HomeMy WebLinkAboutPermit Electrical 1989-08-28a,,I I
Job Locaticn:
Tas Lot llAssessots Map t
Subdiuieton:
7_ 3/ePhone:
AAtmer:
Addvess sf.5 S,
7ybuy.(
Neu
rht
VaLueDate of App Lieaticn
Additicn
RenoCeL
BIdrs lloar<
Recei tl..RESIDENTIAL..
SPFlINGFIEI.I)
zzs Notth sth s;tueitPPLrcATI --/PERMrr
Spr"tngfteld, 1negon 97477
Building Diuision
7 26-37 53
cl
Date:
resont ractors
General
l,Iechanic
Plurnb in
ec tr ca
Elec tr:clanSrr
4
DEI.IOLITIO!! OR !]OVED
Sanita.ry eeser capped at property Lire
Septic tank putped ant filled uith gra:sel
linal - I{hen abcoe i.tens aye ccnpleted
and uhen Cemolt tion is complete or. st!,Li,r-
ture noued ard premises cleaneC up.
Hcnes
Blocking and Set-up
Plunbing connections -- sa)e? and uater
Electrical Connection - Bloeking, set-ut
and plutnbing conneetions rrust be appnc;.ed.
b efot, e requeeting eL ec*-r,i cal inspee tiot
Accessot,e- BuilCing
Pinal - After pcrckes, akirting, decks,etc. are conpleted.
Page 1 of 2
It ia the reaponsibility of tle permit lwlder to see that aLL inapectione ate nade at the propet time, that ecch ad-dress is neadabl.e
frotn the at?eet, and, tlat the permit ca.td is Located at the fnont of the propet,ty.*Buildirq Nuiciot appz,o"*ed plan slnll remai.n on the Builtlinl Stt; at aLL- times.
PB):EDUPE F1R INSPECllert qEQ/ES!:CALL 7
eady forr.,iLL be nade the sane dcy, requests .made
SI?E INSPTC?ION: ?o be nade aftez,ercau;tlon,-ilt pr.tor to set up of
forma.
UNDERSLAB PLUM)!Nq, !!,ECIRTCAL e
MECHA.,4IICAL: To be made before any
uonk ie cottered.
?OOTING & FOUNDATICN: ?o be traCe;Fa=rerrct;s at,e ercazsated and.
forms at,e erected, but prior to
pout"tng ccnarete.
TNSULATT)N/7APOR BARRTFR IilSPEClr)N :
To be rnaCe aj'ter aLL insulaticn and,
required uapon barriel's ane in place
but before atty Lath, gypsun boarC or
rnLL coueting is applied, ard before
oty ineulation is concealed,
DRYWAI,L INSPEC?ION: ?c be made
Aftev,-dT-6wiTTis in ptace,
but prior to any taping.
MASONRI: Steel location, bond
beans, grouting or oerticals in
accordance bith U.B.C, Section
241 5.
WOODSTOVE:
ccnpmfi.
After installation is
26-3769 (tecorder) state your City desigrwted job nutnber,, iob aCdrees, type of inspeeti*r
'inspection, Contractors or A,mers rctne and plane nwrber'. P.equests recei"*ed befcre 7:00 ct
aftet, 7:00 @n diLL be nnde the nest:,nrking daA. 6._) .\ , -_1
Ioun City Designted Job l,lwnber rr, 5l\L\ \ 35
UNDIRGROUIID PLUM9ING, SEWB, W,qTER.
0841!4gl: To be maCe prior to fil-T|Q-iFinchee.
UI|DTRFLOOR PLUI,EINC & MECHANICAL :
oy
floor ineulation or decking.
POST AND BE4M: To be nade pr"iot, toTiil7Tafr6ti-of floor insulition or
decking.
R)ucH PLU!.tBntC. ELE?TRTCAL & MECH:
ANICAL: No uotk ie to be co.-et,edGliTthese inspeettons haue been
made aruL approueC.
PIPEPITACE: Prton to plccirq facingma.terials and before frantng inspee-tion.
FRA\'|INC: Wst be requeeted aften
approual of rough plutnbing, electyi-cal & meclwnical. ALL roofing
bracing & chinmeys, etc. nrast be
cotnpleted. lto uork is to be con-
cealed until this inspection lws
"been nade anC approoed
CIRB e APPRQACH APPON: After forms
at e erect;{T;{nilo1" to pouring
concrete.
SIDEWALK ,9 DR.TIAilAY: Fot, all con-
ct "te p",/G-;ltln street right-
of-?ey, to be made after aLL erca-
oattng complete & form utot'k & sub-
base naterial in place.
IENCE: t{hen complete -- PtooiCe
gate6 or motsable sectians through
P.U.E.
FTilAL PLUMBING
FTNAL MECHANICAL
FINAL ELECTRTCAL
AIL pnoiect conditions, such as the i.nstallation of street trees, conpletion of the
requined Landsccping, etc., rmtst be satisfied befoye the BUILDIilC FINAL canbe requested.
a\ PrNAL B|ILDINT:- The Final Build,ing. Inspection rrust be t,equested after the pinal plwnbing
\_-/ Electrical, and. Mechanical rnspeetions hque been nade ard'apptooed.
*AT,L MANHCT,ES AND CLEANOUT: MI]ST BE /ICEESSIBLE, ADJUSTIIEII| ?o BE M!1DE .4T NO CL)ST ?o c7y
Describe h'ot'k:
l
tr
r
SOLAR ACq.ESS REQ.-*
t
JOB NO L-CO
Bedrooms
Sout ces
P, T,,House
Lot Faces -LOT ?YPE
_ fnterior
_ Cofner
_ Panhandle
CuL-de-sac
# of StorLes
Lot Sq. Ftg.
% of Lot Coueraga
Total Height
Topography
-- Pees --
ITEM FTG l Value Building Volue & Permit
This permit is granted on the erpress cond-ition tlut the. saidrconstruction
iholl", in a-l.L rLspeets, conform'to the 7rdinance edopted h;U the City 9f
ipilrgYlnU, i.netidrng' the 2oning crdinanc-e, regulati1g l;he ccnstructicn
*a "'i"n of Luild.ings,"ond ^ry be suspend.ed ot, reuokeC at cny time upon uic-
Lation of any prcuisions of eaid 1rdinances'
TOTAL VALUE
s.D.c. 7, S x
Butlding Permit
l:ut;e latd:
SLate Receipt #:
Total Clnrges ,(Signed
,11'EM N0.CHARGE Plumbing Permit
No Derson slutll constmtct, inetal|-, aLtet ot'cltanqe -anA ne,-cr ecisting';ir;;b;;"";"iiti"iZ"
"i"t* in xhoi.e or. in part, unless such petson is the
legal possesson of " rZtti pl"iei'i L;,.n'sZ, ercept that a pierson ma'g do
pliiairi uot'k to p"opnrty-inl;h- is o"t'nd, Leased or operated by the appli-
cant.
Fixtures
Residential (1 bath)
Seuer
Wctet'
Pl*nbing Pernit
State
*
Neu/Estend Circuits
Electrico I Permi t
were state Lan requires tlwt the electt'icaL uork be dane by an Electrieal
Contraetor, the eleca'l"cot po"tto" -of this -permit shall not be oaliC until
1711s latel'lus been signed ty the Eleetrical Cantractor'
Seruice
a oo
State oo
Total ,00
NC,FEE CIIARCE Mechqnicol Permit
tzhanst Hoo,7
Vent Fan
PermLt fssuanee
Mechanieal Perwit
*
Sec-urity Depoeit
Storage
l,laintenanee
Permit
Cvtbcu!
SidetsaLk
Fence
Electri.cal 14b91--
Mobile Home
DaLeTf,ant Eraniner
IHAWIAREEULLyEXAMINEDtleeonrpletedaoplicationforpermit'anddo
hereby certify *oi"a-L'L"itioiqyib" hertii is true and cbrrect' and r
irrl1", zn"tlliy taot")iy'ai.d alt uork perforned sltall be done in accor-
dance tLth tnn onai"rT"zr-Jr ;ir" ili zr bpri-ngfield, .and Lh.e .Lass of the
* State of ,tegon p";';;;;;;;s-'to'tie wirt< CesLrib-ed herein, cnd ttnt N0 ,ccu-
pA,cy dlitl be rnade'i7-;;;'"i;;i"r2""it7""1- p)rmieeion of the Buitdins Di-
uision. I furl:he.r, c-ertilit that ,only .onlii"'ton" and erpTcgees uho are in
ZJptl"".L'rLtn cns'zol,'o'Ls 'Ltt be-ueed on thie proiect:
TotaL
T7TAL AM)UNT DllE: *
te
I?TiE
Tatal Charaes
rTEM
Wcodstope
-?otal Clarges
-
State Surchdrae
*
Rceeipt # |r32 Lr-Z
0c-
Date: 2- a
GeneraL
L
Coasjtuctton_!etdel_
rOR 56022
EIectr
z2s North strr streeawLrcarrcN
/PERI',rr
SprLngfieLd, 1regon 9Z4ZZ
BuiL&Lng Ditsiston
7 26-37 53
" RESII_jNTlAL"SPTINGFTELD
North 26th
D\
Job Locaticn:
Subdittision:
Aesessors Map #r6s Iat *299L8349533O
ield, OR 97477
-01r00
asner: Mike Fredrickson
fieldAddt ess:OR Phone: 747-3121
City:zip: 97478
t--t
t-t
value 3400.00Date of epplieatian- 2/20/89
Addi.tion
RemoCeL
Desct"tbe llork:
Fire danrage re[Eir.
x
I-t io the tespottoibility of tte perwit ho&e?ft*, tln atreet, and tltat the pinrit eazd. ie*Building D,ioicion appz,o"*ed pThn sVnLL ni^iin
to aee that aLL insoections ee nade at the ptope" tine, that eaeh ad,4ness is reaCableLocated at the froai of the orooettu.on the Bunlding Site at aLL'ttmes.'
PRocgDUPE FoR rNSPEcrroN.El-Pwsr"cALL726-3769 (reecvde*) state ac,tv city d.estgrn-ted job nunbet,, job aciress, type of inspec=icn,equested and uhen uou ui1-T Eeneady foz' inspection, co;;;"ol;;;- oi a,ners- nane Lnd ptnne nuqbet,. p.equests receixed befc,e z:00 an'*iLL be nade the edze d.as, ";A-.;l;"^La'ilt* z,oo'n "ii tz- ia" th;,;;;;;;ri;;;,E,'Aa.
Y?D /25Iour City Desigrated Job Nutnbey fs:
x
SITE TNSPEC?ION:
escauation, but
forns
trenches.
FNIAL PLUMBTNG
ETNAL MECHANICAL
PTNAL ELEC?RTCAL
?o be nade after
pt*iot, tc set up of
to
W*aork is cooet,ed-
require4 oqot, bmrie?a @e in place
but_ before oty Lath, Wpsun baazC ortnLL eouez,ing is applied, and. beforeoty irnulation i,s concealed.
FO2TrNc & F)UNDATTCN: To be maCeafte" t"enches a?e escaated and.
forms- ate erected, but priot, topout-ing ccnez,ete.
f- DRYI.ALL INSpICTTON: Tc be made
lX I aftet, aLL C"rguaLL is in pZace,but p?ior to any tapirq.
Final - Wen abctte itms ate cqnoleted
and uhen Cqnalition is complete br sfuue-ture moued and. pretrLaes cleaneC up.
4AAS)NRI: Steel Location, bond
beans, grouting ot ueyticals in
accordorce Lrith U,B.C. Section
To
?o be
concrete.
WOODSTOI.E:@;ra.
aLL insu
After instalLation is
0R tiowt
Saritary seuer eapped at properfu Lire
Septic tank p;,nped and filled trith gra:;el
Hcmes
Bloeking old Set-up
Plunbing connectians -- saie? od. aater
Electrical Ccnneetion - Bloeking, set-uD
and_ plutnbing connections m;st b-e- apprctZd.before requesting eleelytcal inspeitpot
Accessory BuilCing
wpyPPLo)! PLUJETNG & MEC\LANT1AL:ro De moie praor to instalLation offloor insulction or decking.
P_)ST 4t!P IEAM: ?o be made pnior toinstallatian o! floon insulation oz,decking.
ROUGH PLU,!BII\?, ELECTRTCAL & !,\ECH-ANICAL: no uoik-7i-t-i-6i-iiieiZZ-za:til these inspections hatse been
mad.e cnd approueC.
EfPEPLACE: Ption to plceirs faeinamaterials and. befot:e fror,in| Zr"pnl_
xLOn.
FRAI.,IING: ltust be requested afterapp-toual of z,ough plwnbing, eiectri_eal & nechanical. ALl. toofin4
bractng &- chinmeys, etc. nust" becomPLeted. Ilo wcrk is to be con_.-cealed until this inspeetion lws'been made anC approoeZ.
CURB & APPRCACH APPON:ee erecteC but prior
After fonnsto paning
SfDEWALK & DRfiEWAy: For aLL con-cr-ete paoirq uithin street right-of-uny, to be maCe after aLL -e*ca-
uating conplete & forn uotk & eub-
base rm.ter.ial in place.Firnl - After pctches, skirting, decks,etc. an,e c.cmpleted.
!Ell!E: Wen conplate -- ptouiCe
gates or motsable sectians thtough
P, U.E.
ALL proiect conditions' such as the i.nstallation of street trees, conpletion of thetequit'ed Landsceping' ete., tm,tet be satiefied. t.ii""-it""-iu-;;r'" F1NAL can be requested..
!tNAL BUTLDTNG: The Final Building rnspection nruat be requested. aftet, the Final plwnbingElectrical, anC Mechanical rnspectio".;i;;; o"n *La"- iri ippri"a. - '
Pege 1 of 2
*ALL I4ANHCLES AND CLEANOIJTS T,IUST BE A CCESSTBLE, ADJUSTIIEIII ?O BE IL4DE Ar NO CCST rO CNY
r
tr
T
JOB NO.
Zone:
TotaL
5 soLAR AceEss REe.-0r r--co C
Gro,Bedrooms
Planl Eraniner Date
f HAW CAREEULLY EXAILINED the eornpleted application for permit, and do
hereby eertify that aLL inforrnation hereon is tv'ue and cow'ect, cnd f
furthet, eet,tifg that any ard aLL uork perforrned sVnLL be done in aecor-
danee vith the Ordinances of the City of Springfield, and the Lats of the* State of 1regon pertaining to the uot'k Cescribed herein, aTtd tVnt N0 }CCU-
PANCY uiLL bb maCe of any structw'e uithout petTnission of the SuiTding Di-
uision. I funthen cez,tifs- that otly contractors cn^d enplcyees dho are in
eanpliance uith 1RS 70L.055 uiLL be used on this pt'oieet
;e3-b?
Aecess
Lace
L.House
Lot Faees -
lleat
Sout ees
# of Stories
?otal Height
Iopography
LCT ?WE
_ fntenior
_ Comer
_ Panlnndle
CUL-de-sac
Iot Sq. Ftg.
% cf Lct Cooenage
o^^^
I?EM EJU x Value Building Volue & Permit
This pemn t is gnanted on the erp?ess cond.ition t?wt the said eonsttaction
stnll-, in all z.bspects, conform to the 0ndinance adapted tiy the City of
Springfield, including the Zoning Crdinance, regulating the ccnstracticn
and. use of buiLdin4s, cnd may be susperd.ed or reuokeC at cny tine upon oic-
T,ation of GnA prcoisions of said 1rdir,ances.
TOTAL VALUE
S.D.C. 1.5 c ,t
Building Permit ((,
Sta.te
3 Receipt #:lotal Charges *
Si.gned:
N0.FEE CHARGE Plumbing Perrnit
No person slnll consttact, instal'!., altev' or ehange anA nea cr etisting
plwnbing or drainage systen in ulole or in part, unless sueh person is the
Legal possessot, of a ,talid plunbet"s L'Lcense, eseept that a pe?son mag do
plwbing uork to p?ope?t! uhich is otned, Leased or operated by the 6ppli.-
cant.
?i*ttpes
Residentia.L (1 bath)
Seuer
Plunbing Pernlt
Nau/Extend. Circuits
Electricol Permit
-rlhev'e fii;ate La.n i,egui"e$ th,at the eLectr'Lcal uork be done by un E\ectrical
Contraetozt, the electz,ical portion of this permit slwlL not be ualil until
the Label has been signed bg the Electuical Cont?acto?.Setwice
State
TotaL *
NC FSE CIlARCE
I Mechonicql Permit
tuhanat HooC
tlcodstote
Vent Fan
PermLt fssuanee
Meclnnieel Pernrtt
.- ENCROACIIMENT .-
Seeuritu Deposit
Storage
Mainternnte
Penrit
Cutbcut
Sida,nlk
?ence
Eleetz,ieal Label
Mobile Hone
TOTAL AMOUNT DUE: *4 bJ3 Date
ITEM
llatpt
?otal Charaes
Pl anni ng & Devel opment
Job. No.0
- gIlT:T OF SPR,IT\TGFIEL'
0FFr,i 0F C0MMUNITY AND ECONOMIC DEVLut)PMENT
225 North 5th Street Date
Buildjng Divis'ion
7,"?/-:82
JOB ADDRESS l.0ot {r'L6fr|
o t
>t+c
4t,
fatsY /h/LL-
N LeE,
{p N TN L
CALL FOR REINSPECTION INSPECTOR
**** CALL F0 R: --- INSPECTI0N 726-3769 ---- INF0RMATI0N: 7?6-3753 ***'(
TO:l,,Jx t ILF Fft€-p At, ( ' eaa/
SPF|lt.6f|ELD
I,IOOD STOVE/INSERT INSPECTION APPLICATION
CITY OF SPRINGFIELD
BUILDING SAFETY DIVISION
225 F 'ifth Street
Springf ield, 0regon 97417
Offi ce :
INSPECTION LINE:
726-3759
7 26-37 69
CITY OF SPFINGF'ELD, OREGO'V
J ob Loc at'i on :loot N.)GL
Assessors Map #:3*Tax Lot #:I L_Oo
0wner:{Y\'t LL Frrfui 1*-3 LowtL)
Address, 6q+ S, 1Ve Phone #:141-ztlt(i@ )
City:
Val ue of
(pt
&State:v-Zi p , qlqtl
Insert:
appr0pr a app ance
Prel'im'inary Inspection is $15.00
l,lood Stove/Insert Permit 'is $15.0
Type of Inspect'ion Requested:
contractor: tTl fite,L-'
installation of insert)
state surcharge
(
0
or to
$0.75
ipr
+
Stove
Address:Phone #:
city:--_---state:Zi p:
Construction Contractors Registration #: Ex pi res :
By sign'ing this permi
required (726-3769).
perm'it is correct and
for wood burni
a ur
t/ appIal
that
f ication, I agree to call for an inspection(s) as
so state that all information on this application/I was provided with the Wood Stove Safety information
inspection standards.
2 2-74
Date
FOR OFFICE USE
c
REQUIRED INSPECTION (S ):I,IOOD STOVE/INSERT
2-)-1o
PREL IM I NARY
Date of App'lication:Job #:
Total Amount Collected:Ls.1{
Receipt #:)5a49 Issued By:
r
c1
9q
checked for Delinquenci r* L/ checked for Historical status . l-"..t)
FiRE DA}4AGE REPORT
OR
ELECTRICAL HAZARD
krcrb'
DATE:t- t 5 -8 ?
TO:
FR0t"l:
SUBJECT:
Building DePartrnent
Springfield Fire DePartment
Structural Damage to Building
lra'lb
tA
8)1.l
Address or location of building
5 q ^aJ
Name of ol',ner
Type of buildjng dFt
(Dwelling, Store,rehous e, etc. )
Est'imated val ue of bu j 1di ng
Estimated loss to building
Date of fire 2- /S-f 4
Location of damage 'in building L 'r
/' /^" ! // u'//t/
(Rcof, Wall, Exterjor,Interlor, e tc. )
Structural weakness as a result of the fire Jar ;./(
6
ta ,L-
a
(Bu d raf ters , Beams , .lo i sts, e tc. )
Add'i iional Derr-jnent'i nformation
2t
El ectri cal Hazard -/
(tiJi ri nq , 0utl ets , etc .
cc {,rd lu {q Jd
Sjqned
kfob'
FiRE DA}4A.GE REPORT
OR
ELECTRICAL HAZARD
DATE:2 _t5 -8?
TO:
FROI,I:
SUBJECT:
Build'ing DePartment
Springfield Fire OePartment
Structural Damage to Building
t_b
Address or I ocation of bu'i'ldi ng
{q ^aJ
Name of ov,ner
Type of building dE1
(Dwelling, Store,re house, etc. )
Estimated value of building
Est'imated loss to bu'ildjng
Date of fire 2- /S-f,?
Location of damage 'in bu'i1di ng /
(Rcof , l,,lal I , Exteri or ,In terior, etc. )
Structural ureakness as a result of the fire
6
I
(Bu n ed raf ters , Beams , .lo i its, etc. )
.r/
El ectlical Hazard t / ' .t' 't',o
(Ui ri nq , 0utl ets , etc .)
l(,CC 'g.t\){q J-tr
Signed
rt/ )/
aa ,t-Jor ;/(
Add.i11cna1 pertinent jnforma tion .Ftt r /.,t.ct J brt ,r /o'r
t:x P.
NO.
S'T'ATE ()T' OIT UGON T.'IRI.) REPORT
STATE ITIRE }'tARSTIAL
r;
I t'or.t'urca.lNy
E DEI']'
o IA
-
- t:otnty --i,AZ.
! s.rn fl Tuc I Tt'ur
I Mo" E rred I Rri
9l I (Tie Line)
'l'l[tE l,\cK lN
SEIiVICE
District of Incident
2 INCIDENT ADDITESS
DAY OF
\YEEK
.L/
! Srt,,,
3 OCCUPANTNAME(hst,First,MI)
{ BUSINESSOWNERNAM (last. Fint, MI)
5 OWNER NAME (Last, Pirst, Ml)
6 FIRE RI'POR'I'ED BY NII)
o_o,J- >
@:-l in
-*jr{ rr,.t .1
APl.l.
o1z
a;
='r{F'J
.E, i{
:1 A
a-r.rl
oo
t.
rl
o
rr
U).l
t.
F'
\1
F)a
U)rl
"l
tr,
?0F'
U)
zl.
Telephone Diret
Municipal Alarm Systcm
tladio
Verbal
No Alarm Rrc'd
ALANM
I PrivateAlarmsysttm
8 # Ot't'tRE SEIIVlcll PERSONNEL
RESPONDED I
9 TYPEOFSITUATIONFOUND
fi Structure Fire
! OutsideStruclu/value
! vehicleFire
! Brush, Grass, l*ave
I Trash, Rubbish
Voice Signal l{uni Alarm
E NotClassifiedAbove
D other(List)
D AutomaticExt.Syst m
! Pre-connect ho*/tank only
[l Pre-onnect hose/]rydrant, standpipe
Over 70 fet
IO N,IETHOD OF
EX'I'INGUISHMENT
PROPER'TY USI]
M MOBII-E
PROPERTY
I2 ROOI\I/ARF]A OF FIRE ORIGIN
E
IN
l3 lGNll'roN FAC'I'OR
l{ Fortl,tot'HnAToFICNI'I'loN
D Self-Extin8uished
D Ntake-shiftsids
! PortableExtinguisher
Hond-laidhose/hydrsnt,standpipe I Undetermined
D ]UasterStreEmDevice
! NotClassifiedAbove
/l l/)b
15 LEVEI,OF
tog E 20 to 29 feer
'u vnl-utt
LOSS
l7 n-Ul\'tAER OF S'l'Oltltls to
7 to 12 stories
l8 IlUll,DlNG AGE (ln Years)
l9 TYPE
20
EX'I'I:NT O}' DAMACE CONFINED TO:
I Theobjcctoforigitr
2 Part 0froom or area oforigin
3 llrxrm oforigin
.l ['ire-rated comp. oforigin
5 Floor oforigin
6 Structure oforigitt
? ExteDded bcyond structure oforigin
g Nodamagcof thetlpe (N/A)
2l Rl:IUARKS WeatherConditiorrs
22 l'ollrv Up Invesligati{,n llequeste(l lfyes, who sill invcstigate
23 Nurnbcr of Injurics
I'ire Se rvire
!.1 l|ember Mnking lleprrt
'15 Arkliti,rurl lnfornution
fet 30 to 49 feet
50 to 70 feet in Flisht
Below grd. level
Not Classified
l3 to 2,1 stories
25 to.l9 stories
50 6tories or more
D 3to{stories
l'la me
trtr
tr
D
D
.E
D
I
2
3
4
5
6
7
SmokerD
2[
3D4f]5n6p
?D
eI
ARnIVAL TllvlE
I
ALARM TIME
/0t^
MO DAY
tts I tst6fl
YEAIr
CENSUS I'RACT ISO CLASSztP
3
DOB (optional)
S-a t -51 1tt,l- 35?o
TELIiPHONt.]
DOB (optional)TELEPHONEADDITESS
171- j t2 I
'fELEPHOhvEDOB (optional)
3-21-y15?// t,7)
ADDRESS
'd st f/"/,
TELEPHOn*E1n-3510DOB (optional)
/o- // -ss
ADDRESS
/oo t P. 2 t tj S, /1./
I Reeived
Mutual
fl ciren E N/A
T OTHER VEHICLES RESPONDED
(do not include PA'., 2-
I OF ENGINES RESPONDED
a
lf OF AERIAL APPARATUS RESPONDED
TYPE OF ACTION TAKEN
Q Extinguish
fJ Investigation
! Removed Haard
I stana
Salvage
Not Classified
MOBILE PROPERTY (Complett line I\l)
LICENSE ilN{OD!lL SERIAL #YEAR T{AKE/
EQUIPI\IENT INVOLVED lN IGNITION (Conplete Line E)
SERIAL T VOLTAGEYEARI\tAKE MODEL
MA'I'I.:RIAI, FIRST ICNITED WAS MADE OF ITEM FIRST ICn{l'lED:
.1
Vehicle and Contents
.00 .00
'to'tAL
.00lluilding
.00
Contents
.006
.00 .00.00/l o .00.00
50,000-99,999 sq ft 500,000 sq ft
ft
I000-{999 sq ft 10,000-19,999 sq ftBUILDING SIZE (Crnd Flr Only)
Unprotectrd Wood Frame
Not Classified Above
Unprotst. Mssonry l:xt. & lv@d Int.Unprotct. Stel Bldg
Prot6t.llxt. &
S PItI N K LER PERFO ttI\,IANCE
I D Fhuipmentopersted
z E F\uip. should haveoper.-did not
3 D &|uip. present fire too small tooper.
9 [ Not clussilicd a&rve
0 ! Undeterminedor not reportcd
8 ft Noequipmentprexnt (N/A)
SprinklereControlledFire: YES E NO D
f,ofHeads O;rned
D I]T[.:C'IO R P I.]It FORMA NCT:
B!
tr!tr
n
tr
D
In rmm of origin-oper.
Not in room oforigin-oper.
In rm of origin-notoper-fire tmsmall
Not in rm of origin-not oper, 6re too small
I n roorn oforigin- not opcr. ID*er disconncct
r\ot in rm of origin-not oper.lrcwer discon.
In room oforigin-not oper. dead buttery
Not in rom of origin-not o6r. dend battery
Nodetectorpresent I l0 Undeterrnined
Numbor of l'atalit ies
Other
'''n'"
/, t /t ,t rt 2- /s, )"qI)ate
'l'ille ./lhle
8r.1.4.10-10 (n-84)
Y-Nx
Other
! cont. on back
DO.\OT WIIITE IN* TIIIS SPACE I -t?5 I