NYC-WTC_000166105

NYC 9/11 Public Portal Document

Instructions to Inspectors—All bor in this form must have an answer. Answ% 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 DIF~ECTOR-OFFICE Z 01 Inspector /- TTh M t~S E ALL . A ) L L 1 pS ,t Name of Candidate M es /t Office Address 7 y`V4 i L ) 7"ni e elate of Examination (Print last name, first name) \ • A: ~/ yP r . jOt ' Instructions to Inspectors—If any asterisk (*) items are marked "NO", terminate the test immediately. See Section Vill for YES NO N/A further information. I. Physical Requirements—Does candidate have ability to: *A. Speak anØ understand English? *5, Hear spokpt I words over a telephone? *C Possess necessary vision? (with co Ctive devices) (correcti devices acceptable) Yes LJ4 No ❑ Yes ❑( ' No ❑ Yes tkf No ❑ B: Buildina Instructions to inspector—If any violation (V) hems are marked "NO", issue a Violation Order at the end of the Test. Test must proceed. II. Records: v. A. Fire dri records current? v B. F1rempiServico Elevator Test Records current? r. C. Keys kept at Fire Command Station Yes 1 No O Yes I No O N/AQ Yes No❑ N/A❑ v. D. Fire Safety Plan and building floo v. E. A Curren list of all floor Wardens and phone v. F. Master window keys available? plan at a Command Station? num,P5r at Fire Command Station? Yes BA No U Yes I1 No ❑ Yes ❑ No ❑ N/A 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 FLOOR Building Inspection--Signs and Charts— v. A. Are èfways roperly lettered? v. B. Are fl properly numbered? v. C. Is floor gram posted? Yes No~ Yes Ui No Yes No v. D. Are stairways re-entry j v. E. Are elevators properly lettered on each v. F. Is floor diagram properly oriented? si ns posted? A elevator nk? ~,/ Yes No O N/A Yes No ❑ N/A n Yes ild 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~aJLr " posted? unobstr led? posted pd current? Yes Li.! No ❑ N/A ❑ Yes LIE No Li Yes UNo ❑ J TOTAL (9) I III. b. Building Inspection—Signs and Charts—Choose one floor for the general floor inspection ~g0fa v. A. Are s sttai)ways properly lettered? v. B. Are floo41iDperIy numbered? v. C. Is floor djagram posted? Yes 02 No1II Yes o❑ Yes [ No v. D. Are stairways re-entry v. E. Are elevators properly lettered on each v. F. Is floor diagram properly oriented? sin, s posted? elevattor k? / Yes_ No❑ N/A Yes Li' No O N/A❑ Yes[?}"10 Li 2.. v. G. Is elevator sign "In Case of Fire, V. H. Are exit doors unlocked, closed and v. 1. Fire Drill Organization Charts Use rSnta~i posted? unobstr ed? posted a current? Yes L( No❑ N/A❑ Yes2'No❑ Yes' 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: ----X ,v i -,. /16SEa,r1-t (V N≤ /u -"' 7-3

NAME OF FLOOR WARDEN CONTACTED FLOOR CHOSEN TELEPHONE NUMBER Does Floor Warden have knowled a of: A. Posit,.i,o-,n/ ~urin fire drill or emergency? B. Notificatio procedures? C. Location of m boxes? YeslltJ s~No❑ Yes No❑ N/A❑ Q. Evacuati location? E. Evacuati procedures? F. Number ofexits on floor? G. Examinin exits on floor? Yes No ❑ Yes No ❑ Yes L~ No ❑ Yes L No ❑ H. Re ortin hether smoke or Fire? 1. Duties e u Fire Warden and Searchers? v. J. Were fire ilis conducted? Yes No ❑ Yes (No _ Yes L~ No ❑__ *K. Floor wardens in numerous floors properly trained? Yes No ~_I /2 L TOTAL(11) // Section B: (II, Ill, IV) 8 or more answered "NO" In Section B falls. SECTION B TOTAL (36) 3 Number of correct answers in this section is . Number of incorrect answers is . Number of N/A answers is _ . M25-14 t&8702561825•P

NYC-WTC 000166305