HomeMy WebLinkAboutSpecial Inspection Fire Damage Report 1989-2-5
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CON'TROL EXP,
NQ Nn
STATE OF OHEGON FIRE HEPOHT
STATE FIRE MARSHAL
FInE DEPT.
ALARM NO.
Sm-
District ofIncident >pri'J(\fic/J f, I). County Lo.n~
-'
MO DAY YEAR DAYOF E'9 Sun 0 Tues 0 Thur
()7 os- I '1 ~'i WEEK 0 0 0
,- Man Wed Fri
SP(!'.'l<,I/,cld
Responding
ARRIVAL TIME
DepL
ALARM TIME
021<;
o Satur
TIME BACK IN
SERVICE
051S-
ISO CLASS
3
02Z(.)
INCIDENT ADDRESS
?;2,')" A~(?<{I S;t-, >fril)uj{idd Of2.
OCCUPANT NAf.1E (Last. First. MI)
0-ID....1c'.S J ~Joh VI
BUSINESS OWNER NAME (least, First, MI) ADDRESS
ZIP
'1741'7
CENSUS TRACT
52
DOB (optional)
t - 21-5'/
TELEPHONE
71b-IOS-(
TELEPHONE
DOB (optional)
5 OWNER NAME (Last, First, MI) ADDRESS
DOB (optional)
TELEPHONE
FIRE REPORTED BY (Last, First. MI)
&..JV1<'> 1 :)Gt(''''I
METHOD OF 0 Telephone Direct
ALARM 0 Municipal Alarm System
o Private Alarm System
, r., "Cf,71-77
Sfn f)<lr'C leI, uf-
DOB (optional)
TELEPHONE
71b - 10'>/
ADDRESS
~g S- 1t5 f( "I ,
eg 911 (Tie Line)
o Voice Signal Muni Alarm
o Not Classified Above
Mutual Aid (extinguisn Dr investigate only)
~ Received 0 Given . 0 N/A
o Radio
o Verbal
O' No Alarm Hec'd
8 # OF FIRE SERVICE PERSONNEL
RESPONDED q
# OF ENGINES RESPONDED
2
# OF AERIAL APPARATUS RESPONDED
/""'"
~j
# OTHER VEHICLES RESPONDED
(do not include PA's) '2
TYPE OF SITUATION FOUND
~ Structure Fire
o Other Prop. w /value
10 METHOD OF
EXTINGUISHMENT
o Vehicle Fire
o Brush, Grass, Leaves
o Trash, Rubbish
o Other (List)
TYPE OF ACTION TAKEN
.1R1 Extinguish
..3 Investigation
o Removed Hazard
o Stand By
o Salvage
o Not Classified
o Undetermined
o
o
~
Automatic Ext. System
Pre-connect hose/tank only
Pre-connect hose/hydrant. standpipe
o Hand,laid hose/hydrant, standpipe
o Master Stream Device
o Not Classified Above
MOBILE PROPERTY (Complete line M)
o Self, Extinguished
o Make,shift aids
o Portable Extinguisher
11 F1~ED ~ROPEWY USE
S ,noi/( -+ci Mil '1
M MOBILE Y!tAR
PROPERTY
PROPERTY COMPLEX (If applicable)
JUJeiUn.:l,
I
MAKE../
SERIAL #
LICENSE #
MODEL
12 ROOM/AREA OF FIRE ORIGIN
L; V; IW\ r OD{'Y\ uJld I
E EQUIPMENT YEAR
INVOLVED
IN IGNITION
13 IGNITION FACTOR
Fi ,e Ii, -F1'rcfiC((e
14 FORM O,F HEA;rOF IGNIJ.'ION
CD/1,:{vLh Dn -+ f',).Y"l
15 LEVEL OF FIRE ORIGIN
fSJ Grade le\'el to 9 feet
EQUIPMENT INVOLVED IN IGNITION (Complete Line E)
t/11?C'vC
(j'r-C(ICI.(('
SERIAL #
VOLTAGE
MAKE
MODEL
/..AJOOcG .....1
; j h ,'J~J
MATERIAL FIRST IGNITED IV AS MADE OF
W.0c?.J.
!,-l'-::'OC.{e i
k
1
neQ+
(() n tl lX, + i 0")
ITEM FIRST IGNITED:
H (ci,.i!.,- be i--,: /Ic'(
o
o
o Undetermined
VV1,:t V1 ,k 1
S{4I~
o Over 70 feet
o Objects in Fligbt
Vehicle and Contents
o 30w 49 feet
o 50 w 70 feet
Contents
~O, ()L'{) .00
~ 10'..::000
o 10 to 19 feet
o 20 to 29 feet
Below grd. level
Not Classified
Other
TOTAL
II S-.. OtJO .00
i <;' , {)O{).OO
16
VALUE
Building
" 7') I nooOO
.00
.00
LOSS
f 2 I~"YX) .00
.00
.00
o 13to 24 stories
o 25 to 49 stories
o 1O,000,19,999sq It 0 50,OOO,99,999sq ft
o 20,000-49,999 sq It 0 100,000-499,999 sq ft
o Unprotect. Masonry Ext. & \\-'ood Int.
.@ p'rotect.ed \Vood Frame
17 NUMBER OF STORIES 0 2 stories 0 5 to 6 swries
.Kl 1 story 0 3 to 4 swries 0 7 W 12 stories
18 BUILDING AGE (In Years) I BUll.DlNG S. IZE (Grnd Fir Only) .0 1000,4999 sq ft
z.. 7 0 0-999 sq ft 0 5000,9999 sq ft
19 CONSTRUCTION TYPE 0 Heavy Timber 0 Unprotect, Steel Bldg
o Steel & Concrete, 3,4 hr. proto 0 Protect. Steel Bldg 0 Protect. Masonry Ext. & Wood Int,
EXTENT OF DAMAGE CONFINED TO: Flame Smoke DETECTOR PERFORMANCE
o 50 stories or more
o 500,000 sq ft
o Unprotected \Vood Frame
o Not Classified Above
SPRINKLER PERFORMANCE
1 0 Equipment operated
2 0 Equip. should have oper.-did not
3 0 Equip. present fire too small to opel.
9 0 Not classified above
o 0 Undetermined or not reported
8 l3. No equipment present (N/A)
1 The object of origin 1 0 0 0 1 In room of origin-opel.
2 Part of room or area of origin' 2 0 0 ~ 2 Not in room of origin-opec.
20 3 Room of origin 3 0 3 0 0 3 In fm of origin-not opec-fire too small
4 Fire-rated compo of origin 4 0 4 0 0 4 Not in rm of origin-not oper. fire too small
5 Floor of origin .5 0 5 0 0 5 In room of origin-not oper. power disconnect
6 Structure of origin 6 !8 6 0 0 6 Not in rm of origin-not opec. pO\lo;er discon.
7 Extended beyond structure of origin 7 0 7 0 0 7 In room of origin-not opec. dead battery
0 8 Not in room of origin-not opec. dead battery
9 No damage of the type (N/A) 9 0 0 9 No detector present 0 10 Undetermined
21 HEMARKS Weather Conditions (optional):
(OLP bO C. I t'W-
/
.Sprinklers Controlled Fire:
YES 0 NO 0
# of Heads Opened
o cant. on back
22 Follow Up Investigation Requested
Y_ NL-
lfyes, who will investigate
23 Number of Injuries
Fire Service
.--8..
I Number of Fat.alities
Fire Service
I Title C .
,C{f'mi /I
I Title
Dale
....--~,
-,C:/
Other
,-f)---
.-2_T
Other
Date
z (S- Igcl
24 Member Making Report
\)d'v!-V1
25 AdditionallnfoGJtion by
rVL /) r?
I v4 L::'"4:rLiA:.
1);( ,
814-440-10 (R-86)
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~cr 66CJ3
FIRE DAMAGE REPORT
OR .
ELECTRICAL HAZARD
q'-(o, \11 (
k~
DATE: Z Is 1'54
/
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f
)
'j
TO:
FR or~ :
Building Department
Springfield Fire Department
. .:1
~/
SUBJECT: Structural Damage to Building
Address or location of building
'X <~) A H'cn Sf-
.
Name of O\'mer
-.JOlrl'" (--o..-..cs
Type of building . Si'I)'"ik ,-Cai'V1;('f dLu.ef{I'n~
- (Dwe1'1ing, Store, \~arehouse, etc.)
I
Estimated value of building. $ r5,OO"O
Estimated loss to building $ i?,OOO- I')r{)OO
Da te of fi re L. /<:; / ~q
Location of damage in building Sovih w,dl i'l 1'\"11"1 100."1 a"..d !1. of-'
yHie J- rooF dIve.. 0rc. burnet.! ii ,i-Ji 10 vytcki-Cl/(
(Roof, Wall, Exterior, rnterior~ etc.)
Structural weakness as a result of the fire
..,., ^ r I. I
PV(fi(/X ;-,':1.TI-us., SVlI "j ("'s
(Burned rafters, Beams, Joists, etc.)
Additional pertinent information
Electrical Hazard
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S i 9 n ed ~l\11t\ 0/1/1 ' ,}117-( [)C.tLuJil
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