HomeMy WebLinkAboutPermit Fire Damage Report 1985-11-25TO:
FROM:
SUBJECT:
Bu i 'l d i ng Depa rtmen t
Springfield Fire Department
Structural Damage to Building
FIRE DAMA.GE REPORT
OR
ELECTRICAL HAZARD
FD-L6
s €s {'zzcY
65/ ra 4
DATE: I i - I r-g r-
cYJt -Address or location of building 1qG
*l'lu, l: ^
Name of ourner
Type of building
Estimated value of building
, Store,house, etc.(Dwe'l I i
$4o o(o
Estimated loss to building $5 oc, c'>
Date of fire lt-7_(-a
Location of damage in building Li"'ru, !"ro, w,rt litr - <;cto ,u T
},lall, Exterior, Interior, etc.
Structural weakness as a result of the fire lu \at e 7
Itcut- ,[,,. i b., k( riinr.1c I a,.,r(incilt al l)o - ,ua 1/ .
(Burned rafters, Beams, Joists, etc.)
Additiona'l pertinent information
ElectricaJ Hazard tl '-.0 L'
(l^liring, 0utlets, etc. )
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Signed -7 7
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DO NOT WRII'E II{ THIS SPACE STATE OF OREGONFIRE REPORT
STATE FIRE MARSHAL
County /-flrue
IREDEPT. -
District of Incident
2 INCIDENTADDRESS
,/b 9S
3 OCCUPANTNAME(T,qt,Fint,MI)
4 BUSINF.SSOWNER (r -rt.LI0
5 OWNERNAME(lst,FiEt"MI)
6 PIRE REPORTED BY (Lagt, PiEt, MI)
CONTROL
NO,
ALARM
EXP,
NO,
Muicipa-l Alam Sldem
Privat€ Alar Syst m
(1
o
-o
@;,l i'rF-it5 15
E'J
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o
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F-
-El
tsEJA
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rd
t{.]r!E
14r.
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t;
t.It,1
t5a
a€
orl
Ff{
EJ
FI'aozrr
c
7
IO ME-IHODOF
EXTINGUISHMENT
D Self-EtlinguiEh€d
TYPE'F SI'TUATION FOUND
p.4tructure Fire
Ll Oureide Struct- w/valw
NUMPEROFVr"*n
D o*er (Lbt)
Ert. Sy8iem
he/tank only
I Pre-mnnec hm/hydrant, standpipe
(Tie Lire)
Voice Sigml Muni Alam
Not Cireified Above
70
D ouj""t" i" ftlsirt
l3 to 24 s6ri€
! zsto.tg
Ert. & Wmd
tr
D
Vehicle Fir
Bruh, Grus, lzave
Trsh, Rubbish
Radio
Verbal
NoAlamRe'd
8 #OFFIRESERVICEPERSONNEL
RESPONDED q
I Had'taid ho*/hydrut,standprpe
I Mutlr Stream Device
I NotClaseifiedAbove
oad.
Below grd, level
Not Clrcifred
f] Undetermined
trtr
PROPERTY USE
M MOBILE
PROPERTY
12 ROOM/AREAOF ORIGIN
E EQUIPMENT
INVOL!'ED
IN IGNITION
13 IGNITION FACTOR
14 FORMOFHEATOFIGNITION
15 LEVELOFFIREORIGIN
level to 9 fet
'6 veLUE
LOSS
Male-ahift aids
Portable Ettinguishe!
1014 I9
20ta29I@t
2 ston6
(.,
30 to 49 fet
50 to 70 fet
E 3tol"to;*7 to 12 gtoria
l8 BUILDINCAGE(InYeG)
19 CONSTRT.]CTION TYPE Hevy Timber Unproect. StEl Bldg
Protet.
20
EXTENT OF DAMAGE CONFINED TO:
I Th€objectoforigin
2 Part of r@m or are8 of origin
3 Rom of origin
,l Fire-rated omp. of origin
5 Flmr of origin
6 Sttucture of origin
? Ertsndedbeyondstructrrof origin
g Nodaugeof thctype(N/A)efl
2t REMARXS Weather Cooditions (optional):
o A)
22 Follow Up Investigation R€qwstrd If y6. who will irvestigate
23 Numberoflnjurim
Fire Seruie
24
Unprotst. MMnry Ert. & Wmd Int.
Wood Frame
SmoleFIame
1
2
3
I
5
6
1
J
I
5
6
,l
wV
tru
tr
Dtr
/tlh
tr6
D
trtr
tr
trl
MO DAY
l r'f tftpiYEAR DAY OT
WEEK fl s*
{**
fl r'*
D w"d
f] Thur I satu
!Fd
ALARMTIME
0tAro rl
ARRIVAL TIME
J /')--7 o J
TIME BACK IN
CENSUS TRACT
t313ltl
ISO CLASS
J?r7 H r717
ztP
14/, - 141, {
TELEPHONEDOB (optioml)
7-t6' i5
TELEPHONEADDRESSDOB (optioDal)
TELEPHONEADDRESSDOB (optional)
DOB (optional)
1'/(2 -{5 1-16 ^ 7./6 (TELEPHONE
1"tL lJ.6v ST.
ADDRESS
f) Given E nll! Ro"ived
f OF AERIAL APPARATUS RESPONDED # OTHER VEHICLES RESPONDED
(do not inclu& PA's)I
# OTENGINES RESPONDED
3
TYPEOFACTION TAKEN
W{'*sosh ! Salvage
fJ I.tot Ct"""itled
Bemoved Haand
Stsnd
MOBILE PROPERTY (Compiet€ line M)
LICENSE IMODELSERIAL l,YEAR I MAKE 0
EQUIPMENT INVOLVED IN IGNITION (Completz Line E)
t^;coti -"toor iusr.AT
SERIAL #VOLTAGE
lliorh.t hrr,rk
MODEL
rqk4
YEAR MAKE
&rue& n.
FIRST IGNITED:
e
MATERIAL IGNITED WAS MADEOF
0ther
.00 .00.00
Vehicle ud ContantE
.00Building
.00
6 aOJ./ oo.00 .00.00.00
500,000 sq ft50,000-99,999 sq ftSIZE (Gmd Flr Only)1000-4999 8q ft 10,000'19,999 sq ft
SPRINKLER PERFORMANCE
I f] Equipment opemted
z I Equip. shouldhaveop€r.-didnot
3 n Equip. pre*nt fire t@ sm8ll ta op€r.
9 ! Not cla*ified above
o f] Undetrmined or not reponrd
8 E/No "qu,p-.nt prent (N/A)
SprinklenContrctledFire: YES E NO n
f of Hade Opened
DETEC?OR PERFORMANCE
3
1
5
6
7
8
I
In mm of origin-oper.
Not in mm of origin-oper.
In rm of crigin-not oper-Iire t@ s@ll
Not in m of orisin-not oper. fire kD 6mall
In rmm oforigin-not opet. powet disconnect
Not in rm of origin - not op€r. powet di8con.
In rom of origin-not oper. dad battcry
Not in @D of origin-not oper. d@d batt€ry
No detrctor prent D 10 Undetemined
fl rVz
NEbet of Fatalitis
tl- 7( - 8(Datr"'n (+le &,fr
DateTitle25
Making
by
I*
Y-N/r
Other
E cont. on bacL
I
TOTAL
{,-t.' ne,n
Alnve
n
Dn
tr
tr
tr
6b?o-darD
\-rit,,
-+
Jj4
J
II
I
I t
.*''jx.li
,!,'l
\'crTY oF SPRINGFTELD, oBX.GoN
Department of Public l,Iorks
225 North 5th Street
BUILDING INSPUCTION DIVISION
JOB ADDRESS:74b /,) 'brt dn
JOB NIJ.I"(BER:
DATE:tzlta/sS7- --f
TO:
NOTE:
t:-:--lAyaz ullL z zbrsa '<E?7-,4,e2rc€ c*A. frlL
tl
A-^lqvn/ /AilA r t-z/+ -rI E TaG, ltBil*zal,lr
-!.
INEORT{ATION:. INSPECTION:
-,,.".
INSPECTOR:
726-37 53
726-37 69 CALL FOR REINSPECTION
. ,.- .: .-... - .," ; .i:, .. , ;: ,- .
s €s f-zzo7+E
FIRE DA}4A.GE REPORT
OR
ELECTRICAL HAZARD
DATE: I (-2r-gg
TO:
FROM:
SUBJECT:
Building Department
Springfield Fire Department
Structural Damage to Building
Address or location of building ')'l c /v, 0 * s7-
r.!.r-l Q
Name of ourner tl
Type of building Sr'^, t l.c .$;rr,; L r{c,,e/( lua
I ling-Store, 6ehouse, etc. )Dwe
Estimated va'lue of bui 1di ng
Est'imated'loss to bui'lding
Date of fire tl - ?{ -a
$4o , c1("o
$S ,oco a-t
Location of damage in building L,'u.,'u, lorru wrrLt /0, - <dr-T
[.Ial I , Exterior, Interior, etc.
Structural weakness as a resu'lt of the fire fu\rue - rt=,_u.,i//
(
ilt c o
(Burned rafters, Beams, Joists, etc.
Additiona'l pertinent information
E'l ectri ca'l Hazard ,t Pnr( -
(W'iri ng , 0utl ets , etc. )
/*u ///",r4
cc:
Signed
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