NAPA EARTHQUAKE; FREE SEISMIC EVALUATION

Please fill in the form as best you can. If you do not know the answer to any of the questions, just leave them blank. If you prefer to have phone assistance with this form, please call (707) 226-5994. Mr. Forbes will get the information he needs from you with a phone meeting.

 

PLEASE FILL IN YOUR INFORMATION:
Last Name:
First Name:
Address of structure:

City:

Zip:
Name of owner, if different:
Phone number of owner:

 
MY CONTACT INFORMATION:
Phone:
Cell:
Email:

Best time to call:
 
Do you feel your family will be safe and your home will withstand the next quake
Yes
No
I don't know
 
STRUCTURE PARTICULARS:
Year structure was built (estimate)
 
Visible and/or known structural damage from the earthquake (Check all that apply)
Foundation cracked
Flat concrete (Garage, sidewalks, room floors, patios) cracking or showing upheaval
Structure moved away from foundation
Outside walls stucco cracking
Outside siding pulling away from house
Not aware of any problems
Other:
 
Since the earthquake, have you noticed any of the following (check all that apply)
Hinged doors or windows not opening or closing properly
Sliding doors not opening or closing properly
Floors sagging a little or a lot
Cracks in ceiling or walls, especially around window or door openings
Other:
 
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