NYC-WTC_000166105

NYC 9/11 Public Portal Document

Instructions to Inspectors—All boxc n this form must have an answer. Answe with 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 F'IRE~~SAF Y DIRECTOR-QFFICE Z 01 ~LLO T " pd I Inspector G.-~/ LLB (A-- -

Name of Candidate_1< /<. 6 _ _ S - Office Address 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 YES NO i N/A further information. I. Ph sical Re uirem is-Does candidate have ability to: *A. Speak and drstand English? B. Hear spoken ds over a telephone? *C. Possess necessary vision? (with co cte devices) (corrective ' es acceptable) Ye 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: , '4riecords current? v. B. Firemen' ervice Elevator Test Records current? v. C. Keys K v. A. Fired —at Fire Command Station? Ye No❑ Yes No❑ N/A❑ Yes Non 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? plan at Command Station? num s( Fir❑e Command Station? Yes o ❑ YesLI No Yes ❑ No L1 N/ G v. G. Building current in actual Fire Drills? * if over 3 months Yes ❑ No ❑ TOTAL (7) Instructions to Inspector—If any violation (V) items are marked "NO", issue a Violation Order at the end of the Test. Test must 12 U

Proceed. III. a. Specific Building Inspection: Special Instructions—Choose one floor for the general floor inspection F OOR Building Inspection—Signs and Charts— v. A. Are staiIpays roperly lettered? v. B. Are ~flo properly numbered? v. C. Is floor diaj2m{posted? Yes I~ No Yese?J No ❑ _ Yes No U v. D. Are stairways re-entry v. E. Are elevators properly lettered on each J V. F. Is floor diagram properly oriented? st ns sled? elevato nk? Yes o ❑ N/A ❑ Yes No ❑ N/A ❑ Yes _ No ❑ 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? unobstru d? posted an rrent? Yes ❑ N/A ❑ Yes —No ❑ Yes No ❑ TOTAL (9) III. b. Building Inspection—Signs and Charts—Choose one floor for the general floor inspection FLO R v. A. Are stairw property lettered? v. B. Are floors pro rly numbered? v. C. Is floor dia m posted? Yes No ❑ Yes No ❑ Yes No U v. D. Are stairways re-entry v. E. Are elevators properly lettered on each v. F. Is floor diagram properly oriented? sicinss sted? elevator ba ? Yes 2 No ❑ N/A ❑ Yes No ❑ N/A ❑ Yes No ❑ v. G. Is elevator sign "In Case of Fire, v. H. Are exit doors unlocked, closed and v. I. Fire Drill Organization Charts Use Stairs" posted? unobstru d? posted and c t? Yes❑ o❑ N/A❑ Yes-4I No❑ Yes oU 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 taken by you." FLOOR WARDENS: dlrl„ NAME OF FLOOR WARDEN CONTACTED FLOOR C OSEN /TELCPHONU NUMBER Does Floor Warden have knowled a of: A. Positio urin ~fire drill or emergency? B. Notification procedures? C. Location of alarm boxes? Ye _)'4o U Yes ❑ No ❑ j Yes ❑ No❑ N/A U____ 3 D. Evacu on location? E. Evacuation procedures? F. Number of exits on floor? G. Examining for exits on floor? Yes o ❑ Yes ❑ No ❑ Yes❑ No ❑ Yes ❑ No H T H. Repo t1 whether smoke or Fire? I. Duties of Deputy Fire Warden and Searchers? v. J. Were fire drills conducted? Yes No ❑ Yes ❑ No El Yes LI NoLi * K. Floor wardens in numerous floors properly trained? Yes ❑ No ❑ TOTAL (11) Section B: (11, III, IV) 8 or more awed "NO" in Section B falls. SECTION B TOTAL (36) Number of correct answers in this section is Number of incorrect answers is . Number of N/A answers is M25-14 16870250-3.R25 P

NYC-WTC 000166229