HomeMy WebLinkAboutPermit Fire Damage Report 1982-09-28FD-l6
FIRE DAMAGE REPORT
OR
ELECTRICAL HAZARD
DATE ? r/.{?
TO:
FROM:
SUBJECT:
Bu'il d'i ng Depa rtment
Springfield Fire Departrent
Structural Damage to Building
I
Address or 'location of buildi ng < ? f 33e
Name of ou,ner *\ /'ner ,4 , *l//'so
Type of building
Estimated value of building
Estimated loss to building
11ing, Store l^larehouse, etc
.id
2o
)
Date of fire q-dtr-?^
Location of damage in bu'ilding Tl*, ^ rr--/'
(Roof, L,Jall, Exterior, Interior, etc.)
Structural weakness as a result of the fire Auf -) o l.L,
(Burned rafters, Beams, "lgists, etc. )
Additional pertinent'information
Electrical Hazard n-*1-. o
(l,Ji ri nq , 0utl ets , etc . )
( dur,ESjqned
r
,
STATE OF OEEGON FIBE REI IT
OFFICE OF STATE FIRE MARSEAL
l. CitylFire Districto
2. Address of Incident
County o LA ISO Class No. o
zip.qzLia-Dept.(3. Date of Alarm: Mo.o Dayo Yr. o Day of weekoTt]E-Hour of Dayo 9143 How Reported. AtARAltbuE-
4. Occupant and/or Business Name
5. Where was occupant at time of incident Property Operating:r Yes X No
-6. Name of Owner Elaee L. ELLrs,ott Address tt57 -tJ -33'Telephone No.-t47-49,+t
?. Fixed Property 11sso ?t,rELLt4/' Property Complexo
(l-Family dwelling, tavern, open lot, street, etc. )
Mobile a
(Multi-use ecupancy)
Takeno I E(fixiGUtstJ^1 Et-f,
R.R. ca, mobi.le home, ctc.)
8. Type (Fire,explosion,(Extlngulshed lLe, lnvesttgalion,rescue. IlEt aid, washdown, etc.)
DO .{OT rN THIS SPApr
R5: V
FrRE DEPT ' sf 8'l -/3o5
colfTRoL.NO. (It ALI\RM NO.
Date Time and Location of Alarm or Incident
A. .MOBILE PEOPERTY INFORMATION
Make Model Serial No.License No. & StateYear
9.
10,
11
t2.
13.
14. No. of Preconnects Used: lYz".oI-2Y2".
15. Mutual Aid:o Given
-
Received
-
Name of other.Depts. Used
No. and Size of Ladders
16. Time Back in Service Tota] Timeo iotal
Wall Framing u)Floor Construction
Exterior Finisho u)Roof Construction
Manhours
Floor Coveringo ?ax)" aeaE
Roof Coveringr M*au17. Approx. BIdg.
18. Interior Finish
tge. ).. u)
19. Ground Area Ft a
20. Floor or Level of Origin'l{
Number of Storieso
21. Closest Point within
22. Equipment Involved(List
ZJ Twne of Material renited o * Cloth Form of Material Ignited o *Linseed oi I soaked cloth-"- tt .p. 96, Ilammable liquid, plywmd, grN, cotton fabric, etc.) (INulation, exterior sidinS, dut, clothing, mattress, etc.)
Room of Origin o * Garaoe
'Room :t Center/Flcclrievel at NW corner of interior store
Isnition.
--
Form of Heat of Ignitiono'k Spontanerrus ignition
ariy type of htng., prcesmg, mechanical or elec. equipment invotved) (Spark, match, elec. ilc, friction' etc.)
:k 0wner placed a drop clotlLin area of oriqin/a carbonlzed cl inker. tvoical
(Brief statement of circmstances or actloE cauing fir: Child playirA wlth fire, themostat failed, pillow on bseb€rd heater, et4.)
detectiono Time to control or blackout fire
Most Probable
24. Ignition Factors.
ne
25.
26.
27.
Estimated time burned before
Description of fire on arrival
action before arrival
Year Make
28. Extent of Flame'
Model No.
Extent of Smoke .Aeen AealrJ Gar.ncc:
(Contined to object, r@m, fl@r, building)tA)tOE.JAl
30.ExtentofWateroamage@ExtentofFireControlDamage(Confined to object, r@m, fl@r, buildlna) (Conftned to obj
. BLla Control Stageo 5,lac 'l J*'o-
ect, r@m, fl@r, buttdira) (Overheated, moulder, Ilme)
features, or protection deficiencies contributing to fire spread NcS CeqeCd Da \,
atr Flauu neL€ |4ATEPtAt-.
to object, r@m, floor,
31. Describe contents and structural
ilp*v4 F<teL toa4
Extension - Weather - fnvesti'o
=Yr-H,tP 7l-qq.
32. If fire extended beyond original occupancy give address * to oickuo outslde
33. Foreible Entry Used: Yes
-
No X Door V/indow 6+ho.
-
34. Estimated lVind Velocity t)
35. Pictures taken: Yes
MPH Direction Weather Condition Lr ?nnt
No
--
By Whom 7.il-NeusQnte
36.
37.
38.
Date
How Reques66 Prtaui
IB-A lE-ll ta-D r,-Alr,-rrl sr ct cm zo-A 20-H zz-A 2Z-B 7!3-A :z;lt-H z4 z5 28-A 28.8 30-A 30-B 30-c 35 37
El,l-4{}-10 (R 6-?91
z2 23
(Beport Continues on Back)
By Whom
38 40
sPca9r52-€l{
Telephone No.
of Situation Foundo
Yes X No
t r-!
Detection and Alarm
39. Fire discovered by whom OLJ lJ L-.{Address
40. Alarm transmittal delayed:r Yes
-
No )( If yes, why?
41. Detectors present in bldg:' Yes
-
No X f., area: Yes
Telephone No.
No
-
Type of detectors
(Smoke, heat, etc., and syEtem or slngle station)
Activated:' Yes
-
No
--
If no whY?
Did detectors alert occupants: Yes
--
No
-
If no why?
42, Auto sprinklers present in bldg.: . Yes
-
No
-
In area: Yes
-
No
-
Type of system
Sprinklers activated: . Yes
-
No
-
If no why?
43, No. of heads opened .
-
Did sprinklers control fire:' Yes
-
No
-
If no why?
(Partial, complete, deluge, ctc.)
44. W'as automatic to Fire a Local Watchman
46 47 48 53 54 55 56 17 58 59 60 6r 63 64 65 66
Casualties and Da
4b. Number of Deaths: Civilian.
-
Fireman .
-
Number of Injuries: Civilian '
-
Fireman o
-
(rf is indicated, complete Casualty Report - Form l0-C)
46. Estimated value of building'0
(Building only)
. s *l4,QQ0
Oa)o
Title
Contents and Equipmerrl o 6 'k8 r 000 . . Other o $= tt 5, 190(ltems within bldg.) (Prop. outside ol bldg.)
47. Estimated Loss to Building
48. Amount of Insurance: Buildingo
49. Inzurance Agent
50. Adjuster
Signed by
Contents and Equipmento a &
Contents and Equipment.c J-1.
Address 2-Q17 u) t L/.*4;u>t F Eue?elephone No.343 -54/t
.Co's
rt)Date
z-:r 45-D43-B 45- It-40
USE THIS SPACE AND/OE SUPPLEMENTAL REPORT FOR ADDITIONAL NARRATIVE OR OTHER INFORMATION
\6. 0ther2 1979, 80FLH Harley Davidson Motorcycle = $3,500.
serial #3G-226-31 H 9
1963, 55cc Honda Motorcycle = 400.
1974, Ford P i ckup, Ore GHE 044 = 2,1+A0.
* Changes and Additions by:n, /r-.o,/ z/ rlfr*t.f";* i"t"t, -r#.-m"
ttr," i
sP.59152-814
(
q5-LIl-A qz-F sz-t)44 45-A
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