Building inspection form for 55 [name], undated

NYC 9/11 Public Portal Document

1OOIZ 71 WTC Visual Survey Form Premise A d :

Block: Residential Commercial Name of Building: Lot: Mix Use Other # of Sto es: AKA's: Building Owner/Management Telephone Number ( ) Name: FAX: Address: On Site Contact Name: Telephone Number Building Owner Management Activities Interior Survey Performed ❑ Yes 0 No Exterior Survey Performed ❑ Yes ❑ No General Clean Up ❑ Yes ❑ No Locations: ACM Clean Up ❑ Yes ❑ No Locations: Air Monitoring ❑ Yes ❑ No Locations: Copies of All Reports and Data Requested Yes

Visual Insuection Results: Facade: Inspected Debris North ❑ NIA ❑ Yes ❑ No ❑ No Visible/Fine Layer ❑Yatol" 0>1" South ❑ N/A ❑ Yes ❑ No ❑ No Visible/Fine Layer ❑Y2to1" 0>1" East ❑ N/A ❑ Yes ❑ No ❑ No Visible/Fine Layer ❑Y2to1" 0>1" West ❑ N/A ❑ Yes ❑ No ❑ No Visible/Fine Layer ❑Y2to1" 0>1" Facade Description:

Roof

Debris: 0 No Visible /Fine Layer M Y: to 1" ❑ > 1" Description:

Setbacks N/A ❑ Floor Debris: ❑ No Visible/Fine Layer ❑ Ys to 1" ❑ > 1" Floor. Debris: ❑ No Visible/Fine Layer 0 to 1" ❑ > 1" Floor Debris: ❑ No Visible/Fine Layer ❑ Ys to 1" ❑ > 1" Floor. Debris: ❑ No Visible/Fine Layer ❑ Y to 1" ❑ > 1" Floor Debris: ❑ No Visible/Fine Layer ❑ Y: to 1" ❑ > 1"

Comments

Date: Inspection by: Agency: Name: Agency:

NYC-WTC 000119693