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"......,. .-', ...,..-' --....-....--..'-.- -.. _'.,_.-.~ '.Oa te . of. Ji re ,0 ( ;:'62.-,'::"7.":) .~--'~... -"~"''''''.~',~,.--_. ~ ~ ~ ,~.,.....-. .... ',',.'''' Location of damage in buil di ng (Roof, Wall, Exterior, Interior, etc.) Structural weakness as a resul t of the fire U ~ 4 (Burned Additional pertinent ~ i nforma ti on rafters, Beams, Joists, etc.) V .,:,.~.. , '.. ~". ~ "vd/ ". .L.. ~ Ii .... Electrical Hazard ,yf~ (Wiring, Outlets, etc.) Signed -- cc I; ,- q3 ilvJ I (11/