HomeMy WebLinkAboutPermit Fire Damage Report 1992-11-8
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FIRE DAMAGE REPORT
OR
ELECTRICAL HAZARD
DATE: }J-?- 92
Building Department
Springfield Fire Department
SUBJECT:. Structural Damage to Building
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Address or .location of building
Name of>o\'lner
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. Type of building
(,L"j.", . /"'''0"-,, .J//-V/t::.i' J~A.~/d:n'
(Dwelling, Store, Harehouse, etc.)
Estimated.value of building $
Estimated loss to building S
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Date of fire
II - Y- 9.2-
. Location of damage in building
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(Roof,Wall, Exterior, Interior, etc.)'
Structural.weakness as a result of the fire
(Burned rafters, Beams, ,Joists, etc.)
Additional pertinent information
. ". ElectricalHa:i:a~d
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(Wiring, Outlets, etc.)
Signed;tt~ _~,~~~~.
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~ " DO NOT WRITE IN THIS SPACE , ST ATE OF OREGON FIRE REPORT
-c"NT~ EXP. STATE FIRE MARSHAL
NO. NO.
D;.tri'lolIndd,nl J ,cJ ~ /;" C/ L- ;.. / ./' Counly L /7 ~:7 /'
'7:,. l MO I DAY l YEAR I ~~F lli! S~ 0 Tua 0 Th" 0 So'"
!I :r /99.2- 0 Mo. 0 W<<l 0 Fn
2 INCIDENT ADDR&SS
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.3 OCCUPANTNAME(lat,Fint,MI) /
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4.. BUSINESS OWNER NAME (Last, Fint. MI)
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Ii OWNER NAME<(Lut, rirlt, MI)
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6 FIRE REPORTED BY u...t. First, MIl
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7 METHOD Oy 0 'Teltpbone D~ 0 Radio
ALARM 0 MunicipalAlannS)'Sttm 0 Verbal
o Prlvlte Alarm System 0 No Alarm Ree'd
8 I OF FIRE SERVICE PERSONNEL , OF ENGINES RESPONDED
RESPONDED 9 )..
1 'OTHER VEHICLES RESPONDED
(do not include PA'I) :L
~AER~E~: S-Pl d- - ;;;277;;)-- ]
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D,pt. Respondin, . ( p ~ /,;., d ./.,,;. /..,/
ALARM TIME ARRIVALTIME 'TIME BACK IN
SERVICE
;2.1/.2-
I ':;CLASS
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ZIP I
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CENSUS TRACT
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DOB (optional)
TELEPHONE
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008 (optional)
TELEPHONE
ADDRESS
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ADDRESS
/j"4s./fhflH?
J61,!,-41
f,U-?j' 7;1..
TELEPHONE
DOB (optional)
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/. )>.!p'-JI 7-3/)..f
TELEPHONE
ADDRESS
DOB (optional)
..1.utual Aid (e:rtirIJUiL. or invatipt.e only)
o Received 0 Given J:t N/A
o VehideFire
o Bruah, Grall. Laves
o Trash. Rubbish
o Self-Elltinruished
o Mab'lhift,icb
o PortableElllinruisher
Ii{ 911 (Tie Line)
o VoiceSiplMuniAlarm
o NotClallifttdAhove
1 lOF AERlALAPPARATUSRESPONDED
o Other (List) I TYPE OF ACTION TAKEN
0' EnirIJUish 0 Removed Hazard
[j Investigation 0 Stand By
o Hand.laid holt/hydrant, ltandpipe
o Muter Stram Device
o NotCluaifiedAbovI
MOBILE PROPERTY (Complete line M)
o Salvace
o NotClallified
9 TYPE OF SI'nJA TION FOUND
.ar Structure Fin:
o OtherProp.w/value
10 METHOD OF
EXTINGUISHMENT
Automatic En. S)'ltem
Pre-connect bOlt/tank only
o Undetermined
11 FIXED PROPERTY USE
o
o
~ Pft..connect bOlt/hydrant..tandpipe
1 PROPERTY COMPLEX (lr applicable)
dr/,V/L / J...L'... /",,::-.
I. MODEL
SERIAL I
I LICENSE I
M MOBILE .1 YEAR
PROPERTY
- \2 ROOM/AREAOFFlREORlGIN
/11/(..// A !! t'" /' ~ "./.f
E EQUIP,.mNT r YEAR 1 MAKE
INVOLVED
IN IGNITION
13 IGNITION FACTOR
1 MAKE
EQUIPMENT INVOLVED IN tGNI'TION (Complete Line E)
J /d~ ,
MODEL
I SERIALI
I VOLTAGE
rl-:,,- r.4/.s- r-
14 FORMOFHEATOFIGNmON
liTEM FIRST IGNITED:
Wd<ld
o Below crd. level
o NotC....ified
Oth~
.00
U Undatermined
TOTAL
1<;t:J~A/1/) .00
"
IS (}() .00
16 VALUE
.00
LOSS
.00
.00
.00
o 5OItOriesormore
.
Noda~oh.bet~'PttN/A)
I 0 , 0
2 IA! 2 0
, 0 , 0
. 0 . 0
, 0 , [j[
, 0 . 0
7 0 7 0
. 0
B 13to241tories
25 to 49 stOne.
o lO,000-19,999lqft 0 1)(),000.99.999aqft
o 20,000-49,999 ~ ft 0 100,000-499,999 IQ ft
U Unprotect. Muonry Ellt. & Wood Int. j!I UnproteCted Wood Frame
o Proteet.ed Wood Frame 0 Not Clualfied Abo\',
SPRINKLER PERFORMANCE
1 0 Equipment operal.ed
2 0 Equlp.lhouldhaveoper.-didnot
3 0 Equip.p~trlfttoolmaUtoopet.
9 0 Not cluau*, above
o 0 Unclttermined or not reported
8 t!' No Iquipmentprnent (N/A)
o &OO,OOOaqft
Sprinklen Controlled Fir.:
I ofHeadt Opened
YESO NOO
21 REMARKS Weather Conditionl (optional):
o cont.onba.ek
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Dn,
-.1.2 Follow Up Investigation IUquested
Y_ N~
Il)'es....howillinvestigate
23 Numbtroflnjuriea
Fire Senrke
J NumbtrofFata.litin
FirrService
Title
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U Additional Informatio~
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814.44(1.10 (R-86)
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