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0_ j J y ITHACA FIRE DEPARTMENT
INCIDENT REPORT
(F-40-1)
?DID: 55009 EXPOSURE: 00 REVISED REPORT:
INCNO: 000284 DATE: 020492 DAY: 3 ALARM BOX: 0002 DIST: ITT
ALARM TIMES: RECEIVED: 1809 OUT: 1810 ARRIVED: 1820 IN SERVICE: 1841
INCIDENT ADDRESS: VERA CL 125 APT, ROOM OR LOT NO:
:ITY, ZIP: ITHACA 14850
)CCUPANT NAME: GORTON SYLVIA
)WNER NAME: GORTON SYLVIA OWNER ADDRESS: VERA CL 125
:ITY, STATE, ZIP: ITHACA NY 14850
kLARM METHOD: 1 SITUATION FOUND: 11 ACTION: PRIMARY: 1 SECONDARY: 3
FIXED PROPERTY USE: 41 PROPERTY COMPLEX: 98 MUTUAL AID: 1
ZESPONSE: PERSONNEL: 008 ENGINES: 002 AERIALS: 001
TANKERS: 000 OTHER: 003
'ATALITIES: FIREFIGHTER: 000 OTHERS: 000
INJURIES: FIREFIGHTER: 000 OTHERS: 000
:ONDITION ON ARRIVAL: 8 PROPERTY VALUE: 6 PROPERTY DAMAGE: 0
'ROPERTY ABANDONED OR VACANT: 2
:GNITION FACTORS:
,REA OF ORIGIN: 57 FORM OF HEAT: 15 TYPE MATERIAL: 34
'ORM MATERIAL: 75 IGNITION FACTOR: 56 JUVENILE INVOLVED: 2
'TRUCTURE FIRES:
3UILDING HEIGHT: 2 LEVEL OF ORIGIN: 2 SPRINKLER PERFORMANCE: 8
:ONSTRUCTION TYPE: 5 FLAME DAMAGE: 9 SMOKE DAMAGE: 9 WATER DAMAGE: 9
:QUIPMENT INVOLVED: 14 ITEM: METAL CHIMNEY MAKE:
IODEL: SERIAL #: YEAR: ??
:F HEATING EQUIPMENT, FUEL USED: 2
)ETECTORS: PRESENT: 1 TYPE: 1
:F DEFECTIVE: BRAND NAME:
[OBILE PROPERTY:
'YPE: YEAR: MAKE:
'IN#: LICENSE #:
[AZARDOUS MATERIALS: CLASSIFICATION:
POWER SUPPLY: 1 PERFORM?: 4
MODEL:
MODEL:
STATE:
AMOUNT
'NVESTIGATION REFERRED TO: DC WILBUR/A FROS DATE REFERRED: 02/04/92
fFFICER IN CHARGE: VANBENSCHOTEN, ASST CH
IFFICER MAKING REPORT:
OMMENTS: CHIMNEY FIRE ]j CREOSOT IN CHIMNEY ONLY CONFINED TO CHIMNEY, 00
CAP PULLED & INSPECT_ED. CHIMNEY NEEDS CLEANING. NOTIFICATION SERVED
MUTUAL AID, TANKER STAND-BY IN STATION FROM 55006.
,SPORT ENTERED: 02/04/92 REPORT LAST UPDATED: 02/05/92 REPORT STATUS:
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UNIFORM CODE FIRE NOTIFICATION
OWNER/OCCUPANT }}
ADDRESS i )�
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City
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DATE
FIRE INCIDENT No.
To reduce the possibility of another fire causing further damage or injury the fire department is required to complete the following notifi-
cation
Section 1197.1c New York State Uniform Fire Prevention and Building Code. The Fire Chief shall notify the Code Enforcement
Official of any fire or explosion involving any structural damage, fuel burning appliance, chimney or gasvent.
Section 1163.9eNew York State Uniform Fire Prevention and Building Code further states, If a fire should occur in any chimney,
smokestack, flue, gasvent, smokepipe or connector, then that item shall be inspected for damage by the Code Enforcement Offi-
cial before any further use.
This form is to verify that the above named individual has been notified of their obligation.
OWNER/OCCUPANT Signature
Fire Department Officer:
Name `• t� CA �j�
Title r I I �� l ';�F 1 AC C' %! -
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Address 7 ; j � ', (� J 7
Code Enforcement Official:
Name —L !� u
Title (k, f
Address VA_J
Telephone Telephone
OCCUPANT - WHITE, FIRE DEPARTMENT - PINK, CODE ENFORCEMENT - BLUE, OWNER - YELLOW