NYC-WTC_000166105

NYC 9/11 Public Portal Document

Instructions to Inspectors—All box n this form must have an answer. Answe rith 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 6' I < ' G 'S' _ Inspector L I ' /J ~~,rL __ Name of Candidate '/ ~` ~~~ /'" Office Address 1'' 7 - c— Date of Examination __L "? . (Print last name, fst name)

A: Instructions to Inspectors—If any asterisk (*) Items are marked "NO", terminate the test immediately. See Section Vill for YES NO N/A further information. 1. Physical Requirements—Does candidate have ability to: *A. Speak and erstand English? *B. Hear spoke rds over a telephone? *C. Possess nece vision? (with c cove devices) (correct evices acceptable) Ye No ❑ Y No ❑ Yes _ No ❑ 8: 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 dril cords current? v. B. Firemen' ervice Elevator Test Records current? v. C. Keys ke l f Command Station rt Yes No❑ Yes No [1 N/A❑ Yes No Li N/A L v. D. Fire Safety P and building flop v. E. A current list of.Wfloor Wardens and phone v. F. Master window keys available? plan at F No Co❑mmand Station? mbar ire Command Station? Y No ❑ Yes.~ No ❑ N/A y v. G. Building current in actual Fire Drills? *if over 3 months Ye 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 Proceed. 111. a. Specific Building Inspection: Special Instructions—Choose one floor for the general floor inspection FLOOR Building Inspection—Signs and Charts— v. A. Are st aysproperly lettered? v. 8. Are flloor operly numbered? v. C. Is floor di va ~ asted? Ye NoLJ Yes 1d No Li Yes td"" No~ v. D. Are stair ys re-entry v. E. Are elevators properly lettered on each v. F. Is floor diagram properly oriented? si n osted? elevator ? Yes No N/A❑ Ye No [1 N/A❑ Yas No II v. G. Is elevator sign "In Case of Fire, v. H. Are exit doors unlocked, closed and v. I. Fire Drill Organization Charts Use Stair ' posted? unobstructe . posted an urrent? j Yes No ❑ N/A ❑ Yes No ❑ Ye-1 No ❑ TOTAL (9) III. b. Building Inspection—Signs and Charts—Choose one floor for the general floor inspection FLOOR v. A. Are stai dys properly lettered? v. B. Are floor operly numbered? v. C. Is floor di t'am posted? Yes No Yes Jr1 No❑ Yesk1 No Li v. D. Are stai ys re-entry v. E. Are elevators properly lettered on each v. F. Is floor dia am properly oriented? si osted? elevator nk? Yes..J No ❑ N/A ❑ Yes PT No ❑ N/A ❑ Yes J No ❑ -sign "In Case of Fire, v. G. Is elevate., v. H. Are exit doors unlocked, closed and v. 1. Fire Drill Organization Charts Use St ' s" posted? unobstructed? posted ti current? 3 Yes No ❑ N/A ❑ Yes No ❑ Ye 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 taken by you." FLOOR WARDENS: O (l bE77 _ _ a NAME OF FLOOR WARDEN CONTACTED FLOOR CHOSEN TELEPHONE NUMBER Does Floor Warden have knowledge of: _ A. Position nn fire drill or emergency? B. Notific cation Procedures? C. Locationof alarm boxes? Yes o~ YesLd No❑ YesE~ No❑ NIA❑ ._ D. Evac, Itn location? E. Evacuation procedures? F. Number of exits on floor? G. Exami for exits on floor? Yes o❑ Yes No ❑ Yes No ❑ Yes No ❑ _ H. Repo g whether smoke or Fire? I. Duties of Depuxt Fire War n and Searchers? Tv. J. Were fire drills conducted? Yes fl No ❑ No U Yes. No ❑ * K. Floor wardens in numerous floors properly trained? Yes. ! No ❑ TOTAL (11) Section B: (11, III, IV) b or more an ered "NO" in Section B falls. SECTION 8 TOTAL (36) Number of correct answers in this section is Number of incorrect answers is . Number of N/A answers is M25-14 16870260.3-R25-P

NYC-WTC 000166232