NYC-WTC_000166105

NYC 9/11 Public Portal Document

Instructions to Inspectors—All boxe n this form must have an answer. Answe iith a "NO" answers to a "V" mandate a Violation Order, "NO" answers to a "*" mandate automatic failure. Check "YES" "NO" or "N/A". ON SITE EXAM FOR FIRE SAFETY DIRECTOR-OFFICE Z 01 ('/ ~~UOYI - Inspector_ '

Name of Candidate i2 S 4 tiD j /1 • Office Address _7 41 Date of Examination _ (Print last name, first ame) A: Instructions to Inspectors—If any asterisk (*) items are marked "NO", terminate the test immediately. See Section VIII for I YES NO N/A further information. I. Physical Requirements—Does candidate have ability to: * A. Speak and nderstand English? * B. Hear spoken ds over a telephone? * C. Possess necessary vision? (with cor ive devices) (cor evices acceptable) Yes J No ❑ Yes- No ❑ Yes No ❑ B: Building Instructions to Inspector—If any violation (V) items are marked "NO", Issue a Violation Order at the end of the Test. Test must proceed. - II. Records: v. A. Fire dri cords current? v, B. Fireme ' ervice Elevator Test Records current? v. C. Keys k Fire Command Station Yes No ❑ Ye No ❑ N/A ❑ Yes No ❑ N/A ❑ v. D. Fire Safety Plan and building floo v. E. A current list of all floor Wardens and phone V. F. Master window keys available? / y pIan ,, r1Command Station? numbe Fire Command Station? Yes No ❑ Ye No ❑ Yes ❑ No ❑ — N/A v. G. Building current in actual Fire Drills? *it over 3 months) Yes No ❑ __ f TOTAL (7) C) jZ Instructions to Inspector—If any violation (V) items are marked "NO", Issue a Violation Order at the end of the Test. Test must Proceed. Ill. a. Specific Building Inspection: Special Instructions—Choose one floor for the general floor inspection doolzi - Building Insp tion—Signs and Charts— v. A. Are star ays roperly lettered? v. B. Are floo roperly numbered? v. C. Is floor dig osted? Yes No L Yes No ❑ Yes No U v. D. Are sta,ways re-entry v. E. Are elevat s properly lettered on each v. F. Is flo diagram properly oriented?

Yes si n osted? No ❑ N/A ❑ elev ank? o El N/A ❑ Yes No ❑ 3 v. G. Is elevator sign "In Case of Fire, v. H. Are exit doors unlocked, closed and v. I. Fire Drill Organization Charts Use St posted? unobstructed? I posted a urrent? Yes No El N/A El Ye No El Yek1 o❑ TOTAL (9) 111. b. Building Inspection—Signs ana Charts—Choose one floor for the general floor inspection FLcfC v. A. Are staff ays properly lettered? v. B. Are flop roperly numbered? v. C. Is flo afm posted? Yes No ❑ Yes No ❑ _ Ye No ❑ V. D. Are staff s re-entry V. E. Are elevator perty lettered on each v. F. Is floor diagram properly oriented? si n osted? elevator., k? Ye No❑ N/A❑ Y No❑ N/Al ? ________Ye Li v. G. Is elevator sign "In Case of Fire, v. H. Are exit doors unlocked, closed and f v. I. Fire Drill Organization Charts Use Stairs" hosted? unobststr'd? posted a1 current? Ye_j No ❑ N/A ❑ Yas No ❑ Yes h No TOTAL (9) IV. Instructions to Inspector—If four (4) or more Items below are marked "NO", the inspector must issue a Violation Order at the end of the test. Test must proceed. This next part must proceed with contacting a Floor Warden within the Building. Read the following statement to the Warden-... 'In the event of a fire on this floor, explain which specific actions must be taker, by you." -- _ FLOOR WARDENS:

NAME OF FLOOR WARDEN CONTACTED FLOOR C OSEN TFLEPHONE NU ER Does Floor Wa en have knowled a of: __ _ A. Positio ring~fire drill or emergency? B. Notificati rocedures? C. Locations larm boxes? Yes No.0 Yes No ❑ Yes No El N/A 1. ) 3_ D. Evacuati ocation? E. Evacuati procedures? F. Num,b~eJ~ exits on floor? G. ExamininJor exits on floor? Yes No ❑ Yes- No ❑ _Yes Li No ❑ Yes No ❑ H. Reportin ether smoke or Fire? I. Duties of Deput Fire Warden and Searchers? v. J. Were fi 'dills conducted? Yes No ❑ Yes ❑ No L1 Yes t' 1 No ❑ *K. Floor wardens in numerous floors properly trained? Ye No ❑ __ TOTAL (11) Section B: (11, III, IV) 8 or more answered "NO" in Section B falls. SECTION B TOTAL (36) Number of correct answers in this section is Number of incorrect answers is __ U . Number of N/A answers i M25-14 15$10250-3-R25-P

NYC-WTC 000166226