NYC-WTC_000166105

NYC 9/11 Public Portal Document

Instructions to Inspectors—All boxt 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 FIRE SAFETY DIRECTOR-OFFICE Z 01 io I S '01 1 Inspector LV •

Name of Candidate ` 6 I Office Address. ! 1~/ U' AV/• Daterof Examination /t (Pant last name, first name) A: Instructions to Inspectors—if any asterisk (*) Items are marked "NO", terminate the test immediately. See Section Vlll for YES NO N/A further information. 1. Physical Requirements—Does candidate have ability to: *A. Speak and understand English? *B. Hear spoken words over a telephone? j C. Possess necessary vision? (with c rrectivo devices) (correct' a devices acceptable)

B: Yes No ❑ Yes No ❑ Yes 7 No n 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 drill records current? v. B. Firem n's Service Elevator Test Records current? v. C. Keys k t at Fire Command Station Yes NJ No ❑ Yes No ❑ N/A ❑ Yes No ❑ N/A n X v. D. Fire Safety Plan and building floc v. E. A current list of all floor Wardens and phonel v. F. Master window keys available? plans Fire Command Station? num,pfs at Fire Command Station? Yes ii No Li Yes No❑ Yes❑ No N/A _ v. G. Building current in actual Fire Drills? *if ov r 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 Proceed. III. a. Specific Building Inspection: J Special Instructions—Choose one floor for the general floor inspection FLOOR Building Inspection—Signs and Charts— v. A. Are tairways roperly lettered? v. B. Are floors property numbered? v. C. Is floor iagram osted? Yes R No Yes No ❑ Yes No Li v. D. Are stairways re-entry v. E. Are elevators pr perly lettered on each v. F. Is floor diagram properly oriented? si ns posted? elevaJr. bank? Yes No ❑ N/A ❑ Ye4N No ❑ N/A ❑ Yes'( No ❑ v. G. I elevator sign "In Case of Fire, v. H. Are exit doors unlocked, closed and v. 1. Fire Drill Organization Charts Use Stairs" posted? unob tructed? posted and current? Yes L No ❑ N/A ❑ Yes No ❑ Yes ❑ No - ` TOTAL (9) III. b. Building Inspection—Signs and Charts—Choose one floor for the general floor inspection FLOOR v. A. Are Stairways properly lettered? v. B. Are floors properly numbered? v. C. Is floor diagram posted? Yes l No ❑ Yes No ❑ Yes I No C ) v. D. Are stairways re-entry v. E. Are elevators prop rly lettered on each v. F. Is floor diagram properly oriented? i posted? elevator bank? Yeslr No 0 N/A 0 Yes N No [I N/A Li 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 Sta' s" posted? unobstructed? posted and current? Yes t No 0 N/A ❑ Yes No ❑ Yes ❑ No I — — TOTAL (9) W. 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:

NAME OF FLOOR W DEN CONTACTED FLOOR CHOSEN TELEPHONE NUMBER Does Floor Warden have knowledge of: A. Position durin fire drill or emergency? B. Notifica ion procedures? C. Location of alarm boxes? Yes No~ Yes No ❑ Yes No ❑ N/A ❑ D. Evacu tion location? E. Ev nation procedures? F. Nurn r of exits on floor? G. Examining for exits on floor? Yes 3 No ❑ Yes l,Ll No ❑ Yes ' No ❑ Yes No ❑ X H. Reporting whether smoke or Fire? . Duties of Deputy Fire Warden 1and Searchers? v. J. Were fire drills conducted? Yes No ❑ Yes No U Yes' I No ❑ *K. Floor wardens in numerous floors properly trained? Yes No ❑ TOTAL (11) Section B: (11, III, IV) 8 or more answered "NO" in Section B fails. 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 1rr970250$R25•P

NYC-WTC 000166248