NYC-WTC_000166105

NYC 9/11 Public Portal Document

Instructions to Inspectors—All boxes .his form must have an answer. Answers v, 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 SAF ,E 7Y DIRECTOR--OFFICE Z 01 4 / a 05-f'? J LyzC - Inspector________________ ° Name of Candidatel`~~l r S4S!u 1-J S Office Address Al 7 ' __ Date of Examination (Print last name, first name) V /, / A: A

Instructions to Inspectors—If any asterisk (*) items are marked "NO", terminate the test Immediately. See Section VIII for YES i NO N/A further information. I. Physical Requirements—Does candidate have ability to: *A. Speak ang understand English? *C. Possess ne essary vision? I * B. Hear spoken words over a telephone? (with ,c_o ective devices) (correcti ddevices acceptable) Yes 1T No ❑ j Yes L5d' No ❑ Yes L No ❑ B: Buildina 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 ecords current? v. B. Firemen' Service Elevator Test Records current? v. C. Keys ke at Fire Command Station. Yes No❑ YesL No❑ N/A El Yes t No❑ N/A❑ J 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 Fire Command Station? numbs at Fire Command Station? Yes No ❑ Yes 1 No ❑ Yes ❑ No ❑ N/A V. G. Building current in actual Fire Drills? (*if over 3 months) Yes No ❑ If TOTAL (7) O 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: Special Instructions—Choose one floor for the general floor inspection Building Inspection—Signs and Charts— FLOOR v. A. Are s taj'ways operly lettered? st v. B. Are f rs properly numbered? v. C. Is floor diagram posted? Yes L! No M Yes Li No❑ Yes No v. D. Are stairways re-entry v. E. Are elevators properly lettered on eacfri v. F. Is floor diagram properly oriented? scions posted? elevato ank?/ - Yes No ❑ N/A ❑ Yes No N/A ❑ Yes LI No LI 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 irs" posted? unobsstr}+cted? posted and current? Yes 1!l No❑ N/A❑ Yes td No❑ Yes [I] No 1t TOTAL (9) III. b. Building Inspection—Signs and Charts—Choose one floor for the general floor inspection FLOOR v. A. Are stapways properly lettered? v. B. Are floor roperly numbered? gra posted? Yes No ❑ Yes No ❑ Ye _ No C1 v. D. Are stairways re-entry v. E. Are elevators properly lettered on each v. F. Is floor di am properly oriented? si ns posted? elevator, bank? Yes 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 arm current? Yes Ll' No ❑ N/A ❑ Yes No ❑ Yes [el" No I -- -~ — — - --- 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 by you." FLOOR WARDENS:, c- / `-J C% eI/j 1 - — • /~17Y NAME OF FLOOR WARDEN CONTACTED FLOOR CHOSEN TELEPHONE NUMBER Does Floor Warden have knowledge of: _ A. Positio uring fire drill or emergency? B. Notif fie1 procedures? C. Locatio alarm boxes? Yes Li No ❑ es Li No ❑ Yes LJ No ❑ N/A ❑ D. EvaEvac i6n location? E. Evacua ' n procedures? F Number of exits on floor? G. ExaminigMrexits on floor? Yes L l No ❑ Yes 1 l No ❑ Yes ❑ No ❑ Yes k1 No ❑ H. Re ortin whether smoke or Fire? I. Duties o e uxtt Fire Warden and Searchers? v. J. Were fire rills conducted? Yes No ❑ Yes LF No LJ Yes No ❑ * K. Floor wardens in numerous floors properly trained? Yes No ❑ TOTAL (11) Section B: (11, Ill, IV) 8 or more answered "NO" In Section B fails. 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 16$102503-R25-P

NYC-WTC 000166259