HomeMy WebLinkAboutMiscellaneous - 60 COTUIT STREET 4/30/2018 60 COTUIT STREET U-1
210/023.0-0065-0000.0 i
' .
MASSACHUSETTS MASSACHUSETTS
FIRE INCIDENT REPORT STATE FIRE MARSHAL
| | fdid { incident no. | exp | date | day | alarm tm | arry tm | time in serv |
A ) |
| situation found I | action taken 7-7- mutual aid |
B | |
| fixed property | | ignition factor \ |
� C | |
| correct address I zip code | census |
D | |
�
� | | occup. name last, first, mi | telephone | room or apt |
E | |
| | owner name last, first, mi I address | telephone |
� F \ i
| | method of alarm | | district I shift | no. alarms |
G \ |
\ { #fire service | #tankers { #engines | #aerial app | # other vehicles |
Hl Oluse used I |
| hazardous material | substance | special equip used {
\ |
� | numbers of injuries \ number of fatalities | rescues |
I | |
{ mobile property I { vehicle stolen ? | estimated total dollar |
J | |
| insurance company itotal insurance | claim paid |
) 00 |
� \ year { make | model | color | lic no ivin# |
|
{
| I i f equip involved ! year | make Imodel | serial no |
I |
| complex i i area of origin | equip inv in ignition |
K | |
| form of heat ignition | material ignited | form { type | |
L | |
\ method of extinguishment | | level of fire origin { |
M \ |
) numbers of stories | | construction type \ |
| |
�
� | extent of flame damage I y extent of smoke damage � |
� N | |
| detector performance \ | sprinkler performance { \
P | |
| if smoke spread { material generating | form | | type | |
I beyond room I most smoke : } 1001 i 001
Qi |
R l weather conditions | |
| -------------------- | entries contained in this report are intended for |
I COLD | The sole use of the state fire marshal. Estimat— |
�
I LOW 301S | ions & evaluations made herin represent "MOST \
I CLEAR SKIES | LIKELY" & "MOST PROBABLE" cause & effect. Any }
{ | representation as to the conditions outside the |
) | State Fire Marshals Office is neither intended nor |
| {
|
o,u�
` rage 3.sop CHECKLIST FOR CARBON MONOXIDE
Location of Incident: �o ir � �� S r Date of incident
QUICK CHECKLIST OP OCCUPANTS
Headache yes no Fatigue yes no
Nausea yes, no Dizziness yes no
Confusion yes no
Are any members of the household feeling ill? yes no
Do the residents feel better away from the house?yes no
Since the detectoes alarm went off,what have you done?
Shut.off carbon monoxide sources yes nom
If yes which sources
Let in fresh air? yes no
If yes how did you let the air in w i k c6 cJ s
How long did you let the air in iS h,1-ii .
PPM reading ambient outside the dwelling 3 P P��
Il'ighest PPM reading in the dwelling ,57 P PM
Carbon monoxide detector present? yes_L_ no
If yes list the number of detetors locations and make,and serial number of each below.
I. A /57 4LPleT
2.
3.
4.
Which detector(s)by number above activated?
SOURCE CHECKLIST LOCATION PPM READING}
Chimney clogged flue,blocked opening
Fireplace(s) Natural gas,LPO,Wood(indicate type for each fireplace)
1. U00P -5T 3. -
2._ 4._
On Appliance (if Gas Company on Scene they can perform this check)
(IF MORE THAN 1 OF THE FOLLOWING APPLIANCES LIST EACH ADDITIONAL
ON THE COM AMS PAGE WITH ITS LOCATION,AND PPM READING)
re6igerator /57— �2 PPS
stove 157- 2
vent over stove —-----
clothes dryers Pr'r
water heater (chimney pipe)
furnace (gas,oikleaking flue/chimney pipe L455 C) pj'°y
barbacu 6�
e in eclosed or semi enclosed area
Oil burner —
car gage
Entranceway from garage to house
Name of individual operating the CO monitor k T , F o G 49 r/
Paw completing the Checklist. 4 T F"o 6rA2 r�
Address o ccgTv �'�
S Title of File
Page of
Date File Open:
Date file closed:_
Doc Document/Action Title Date of Refer to other Purpose of�ocurne�nt Act
action Document/ doeurruent/
Num. / ion and
Action -Department
Board of Ap.peads - Board of Heal h Plannin. Board ;
9 Conservation Commission - Building-
Departrr�
e�t '—