HomeMy WebLinkAboutDIS2011-00019 - FIR Inspections - 5/29/2010 r
MASON COUNTY FIRE MARSHAL
L-110 A, Q�VA
'os- 2 9 - min e!F) 063'�q
FIRE
INVESTIGATION
REPORT
Completed by:
MCFD Incident #:
MCSO Case #:
Incident Date: os-a 9 ` 2-aia
Address: ti i o r>F AL11D
N Mason County Bldg. III — P.O. Box 186 "Shelton,Washington 98584"
FAX (360)427-7798" PHONE(360)427-9670 ext. 273
pppppp- Fire Investigation Report
By:
MCFD Incident M
MCSO Case M
Incident Date: OS-a9"
Address: t�o N A I
1, Genera/Incident Information
Date: dS-a01 - ao/d �.-•� 9$5�
Address: L-110 AIAF
Reporting Party:
Call Type: 57��c�• �'
Time of Call:
Dispatched:
2, Building Information
Building Construction Type:
Building Use:
Fire Alarm System:
Automatic Fire Sprinklers:
Obstructions to Access or Fire Protection Equipment:
Position of Doors & Locks Upon Arrival:
3, Occupant/Owner Information;
Occupant: ba,44- L
Occupant Phone:
Owner:
Owner Phone:
Owner Address:
4, Insurance/Loss Information;
Insurance Company: FAA/ I NSv�-�ivG�
Agent: T°Nl RING- gap L, x
Agent Phone:
Agent Address:
Policy #:
Policy Amount:
Estimate of Loss Structure:
Estimate of Loss Contents:
Fl A4?-c L/�I ivt � I V I GIN �L5
5. Origin and Cause
Area of Origin:
Point of Origin:
Ignition Source:
Cause:
/�/�S /���'" �����L `1�.��ik c-aiv7��c/C/ 9�—�.t� �cl�'S!>i�✓C,' �c�
Page 2
Fire Investigation Report
By:
MCFD Incident#:
MCSO Case#:
Incident Date: z, -19` 2010
Address: 9140 Pl;- L'owd u
Incident Narrative;
DESCRIPTION.'
OBSERVATIONS.•
INTERVIEWS:
DOCUMENTATION.'
OPINION: F,,,4e- A446 Q c',�Ax-/
Page 3
l S 1 3 13n An A,19- �a10
• y2�- �?'- C 3
-ry c
.1)i�s�
7VrS o b l4,V•'" ^c,D kvA ►c cs a6� ,�,�J off/ / 'a
S I L_ S J ✓ S.�t�''L4A-)
�L/
MASON COUNTY FIRE MARS
Mason County Bldg.III 426 W Cedar St
PO BOX 186 Shelton,WA 98584
_ (360)427-9670 Ext.273
CODE ENFORCEMENT FIRE INSPECTIONS FIRE INVESTIGATION PUBLIC EDUCATION
INCIDENT STATEMENT
MCS CASE NO.: DATE:
INCIDENT NO.: HOUR: A.M./P.M.
TAKEN BY:
STATEMENT OF: AGE: t
ALIAS:
ADDRESS: `4/Go /Nj�-- - SonJ �QGr[ wit SS PONE:
DATE OF BIRTH: PLACE:
OCG-UPATION: EMPLOYMENT STATUS:
PAGE OF