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_ 11670 SW BULL MOUNTAIN ROAD
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Ciry of Tigard` Oregon
Rapid Damage Assessment Form
BUILDING DESCRIPTION: OVERALL RATING: (Check one)
Name: INSPECTED(Green) ❑
d4 00 Exterior only
Address: Ml PGS Exterior &Interior
LIMITED ENTRY (Yello;v) ❑
No.of Stories � UNSAFE (Red) ❑
Basement: Yes No ❑ Unkno
INSPECTOR:
Primary Occupancy: Dwelling Inspector ID
Affiliation
Other Residential ❑ Commercial U Office U
Industrial ❑ Public Assembly U School U INSPECTION DATE:
Government ❑ Emer.Serv. U Hospital ❑ Mo/day/year
Other Time am pm
Instructions: Review structure for the conditions listed below. A "yes" answer to 1, 2, 3, or 5 is ground., for
posting entire structure UNSAFE. If more review is needed, post LIMITED ENTRY. A "yes" answer to 4
requires posting AREA UNSAFE and/or barricading around the hazard. Hazards such as a toxic spill or an
asbestos release are covered by 6 and are to be posted and/or barricaded to indicate AREA UNSAFE.
Condition Yes No Morree ke�
tial cvie�zzvv
1. Collapse,Marolla�Se,,br building off foundatir ❑ L)
N Jg
2. Building or story noticeably leaning ❑ U U
3. Severe racking of wall,obvious severe damage and distress ❑ U ❑
4. Chimney, parapet or other falling hazard U U ❑
5. Sovere ground or slope movement present ❑ U U
Other hazard present: 7 IElf G%/V SZ`= ❑ U
Recommendations:
❑ No further action required
U Detailed Evaluation required (circle one) Structural Geotechnical Other
U Barricadef needed in the following areas:
• Other:
Posted at(hipA essment: Occupants Notified to Vacate Temp Ho�ZNo
g Req.
J Yes /' No ❑Yes No U Yes ❑ ?
Comments:
Estimated Damage ❑ 0% ❑ 25% U 50% U 100%
cm �p aN-J t � �i�0.) ICE USE ONLY