HomeMy WebLinkAboutPermit Fire Damage Report 1985-01-02m-16
FIRE DAI'IA.GE REPORT
OR
ELECTRICAL HAZARD
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TO:
FROM:
SUBJECT:
DATE: / - 2 ^vs''
Bui'lding Department
Springfield Fire DePartment
Structural Damage to Building
Address or location of bui'ld'ing ,/ t/o d/?/z/ /-{zz-t
Name of ourner Kettrt'e ,(rly
Type of building
Dwel I i ng , Store, Warehouse, etc.
Estimated value of building t/o , ab0
Estimated 'loss to bui lding $3oo ' ao ?tzzxtc,4z 4n:g<-
Date of fire rd -g{
Location of damage in bui'lding
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Frt u hre. Br,rrrrro oor
(Roof, l.lall, Exter ior, Inte rior, etc. )
Structural weakness as a resu'lt of the fire ,,Ltre {
(Burned rafters, Beams, Joists, etc.)
Add'itional pertinent information
Electrical Hazard fuesps 'e/<)OAerrl
cc:
S i gned
€ruzz
(Wi ri ng , 0ut] ets , etc.
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T0: Electrical inspector
Pl umbing Inspector
Bui I di ng Inspector
Mechan'ical Inspector
Envi ronmental Inspector
EXPLANATION OF REFERRAL
SPRINGFIELD FIRE DEPARTMENT
INSPECTION REFERRAL FORM
FD- I 66/83
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Date of Referra'l /- A-Ps
Inspe ct'ion Number
0ccupan
Address / f
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ACTI0N TAI(Et,l (Attach copy of orders)
Date
By
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