NYC-WTC_000166105

NYC 9/11 Public Portal Document

Instructions to Inspectors—All boxes on form must have an answer. Answers wit' "NO" answers to a "V" mandate a Violation Order_. "NO" answers to a "*" mandate automat... railure. Check "YES" "NO" or "N/A". ON SITE EXAM FOR FIRE SAFETY DIRECTOR--OFFICE Z 01 (L3ilL_-__ Inspector ±T J/I MES F. LAVFLLF Name of Candidate PEP K II W.S 7? A RET E~ Office Address_7 ( L 1> TiPkDF i K Date of Examination.- (3 / (Print last name, first name)

A: hi= W "{O RK a•. ldcty, Instructions to inspectors—If any asterisk (*) items are marked "NO", terminate the test immediately. See Section VIII for YES NO N/A further information. I. Physical Requirements—Does candidate have ability to: *A. Speak and understand English? *B. Hear spoken words over a telephone? *C- Possess necessary vision? -,/ (with —coJr ective devices) (corrective devices acceptable) Yes No❑ Yes[ No Eli Yes 1 }"' No [I 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. 1I. Records: v. A. Fire dril} records current? v. B- Firem ervice Elevator Test Records current?j v. C. Keys ke t Fire Command Station. Yes No❑ Yes L No❑ N/A ❑ Yes No EJ N/A❑ v. D. Fire Safety Plan and building flop v. E. A current list of all floor Wardens and phone v. F. Master window keys available? plan at re Command Station? numbe at Fire Command Station? Yes 1 No [1 Yes LI No ❑ Yes ❑ No [I N/A r#( 2 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 Proceed. Ill. a. Specific Building Inspection: / Special Instructions—Choose one floor for the general floor inspection 3 FLOOR Building Inspection—Signs and Charts— v. A. Are staJ' 'ays operly lettered? floo v. B. Are fl 'properly numbered? v. C. Is floor diagramposted? YesLJ NoII Yes LV No❑ Yes [11 No L) Z v. O. Are stairways re-entry v E. Are elevators properly lettered on each v. F. Is floor diagram properly oriented? si ns posted? L elevator bank? Yes No❑ N/A Yes❑ No [Y N/A LA Yes❑ No L/' 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? unobssttru d? postedVd current? Yes [I No Lj~" N/A ❑ Yes LW No ❑ Yes I No TOTAL (9) III. b. Building Inspection—Signs and Charts—Choose one floor for the general floor inspection FLOOR v. A. Are stacways properly lettered? v. B. Are floors properly numbered? J v. C. Is floor diagram posted? , Yes No❑ YesLV No❑ Yes ii No a' Z v. D. Are stairways re-entry v. E. Are elevators properly lettered on each I v. F. Is floor diagram properly oriented? si,,99__n,s posted? elevator ank? Yes LJ No❑ N/A Yes LNo❑ N/A LI Yes❑ No v. G. Is elevator sign "In Case of Fire, v. H. Are exit doors unlocked, closed and v. 1. Fire Drill Organization Charts Use Stairs" poste.? unob~struyted? posted andcurrent? / Yes ❑ No N/A❑ Yes L1 No❑ Yes No ❑ 2. TOTAL (9) IV. Instructions to Inspector—If tour (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 WARD S: osEin'N t Ey, rvS _ /0 3 3 NAME OF FLOOR WARDEN CONTACTED FLOOR CHOSEN TELEPHONE NUMBER Does Floor Warden have knowledge of: __ A. Positio Burin fire drill or emergency? B. Notification procedures? C. Location-°f alarm boxes? Yes L No ~ Yes I No ❑ j Yes ICJ No ❑ N/A ❑ D. Evac, 3i6n location? E. Evacuat' procedures? J F. Number exits on floor? G. Examining for exits on floor? Yes LUU No ❑ Yes No ❑ Yes L No ❑ Yes P4 No ❑ Roportig whether smoke or Fire? H. Report' I. Dutie,~s 9f De put Fire Warden and Searchers? v. J. Were (firms drills conducted? Yes7No❑ Yes lY NoIJ _ Yes L1 No❑ 3 *K. Floor wardens in numerous floors properly trained? Yes No ❑ f TOTAL (11) / Section B: (II, III, IV) 8 or more answered "NO" in Section 8 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-I4 16$70250-3-ii25-P

NYC-WTC 000166291