NYC-WTC_000166105

NYC 9/11 Public Portal Document

Instructions to Inspectors—All boxes 1r this form must have an answer. Answers h a "NO" answers to a "V" mandate a Violation Order, "NO" answers to a "*" mandate automatic failure. Check "YES" "NO" er 'NiA . ON SITE EXAM FOR FIRE SAFETY -OFFIC DIFECTOR- i Z 0t — Inspector _J A7 Name of Candidatev~ I—Sn ''` lax/ e Address_' _ (Print last name, first name) — — Date of Examination A: Instructions to Inspectors—if any asterisk (*) items are marked "NO", ter inate the t st immediately. See Section VIII for YES NO N/A further Information. I. Physical Requirements—Does candidate have ability to: * A. Speak and j,mderstand English? * B. Hear spoken words over a telephone? *C. Possess necessary vision? (with,-corr ive devices) (corrective evices acceptable) Yes No ❑ Yes LIV No ❑ Yes No I B: 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 d-ri114ecords current? v. B. Firemen)-Service Elevator Test Records current? v. C. Keys kke, t at Fire Command Station. --` Yes 1 ' No❑ Yes Lei' No N/A❑ Yes No Li N/A❑ 3 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 FJie Command Station? number at Fire Command Station? YesL.1Y No Yes Li No❑ Yes Ii No N/A L9' 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 /(J (J Building Inspection—Signs and Charts— FLOOR v. A. Are stair ays roperly lettered? v. B. Are fl or properly numbered? v. C. Is floor di gram posted? Yes LLY No Yes No ❑ _ Yes Lt No ❑ v. D. Are stairways re-entry v. E. Are elevators properly lettered on each v. F. Is floor diagram properly oriented? Si ns osted? elevat r k? Yes No ❑ N/A ❑ v. G. Is elevator sign "In Case of Fire, Yes L No ❑ N/A ❑ Yes 9 - '~No ❑ v. H. Are exit doors unlocked, closed and F v. I. Fire Drill Organization Charts 3 Use Stair ' posted? unobstruct d? posted aØ.. 3 Yes LWNo ❑ N/A ❑ Yes No ❑ Yes b current? No U TOTAL (9) 111. b. Building Inspection—Signs and Charts—Choose one floor for the general floor inspection

v. A. Are stai ays properly lettered? v. B. Are floor ..properly numbered? Jv. C. Is floor gram posted? _ Yes 11 No ❑ Yes Pi No ❑ I Yes No ❑ v. D. Are stairways re-entry A v. E. Are elevators properly lettered on each I v. F. Is floor diagram properly oriented? '~ signs posted? elevator ank? YesL~-Y 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 anJ v. I. Fire Drill Organization Charts Use Stairs" posted? unobstr d? posted ❑ current? 3 Yes ❑-"No ❑ N/A ❑ Yes 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 ~ taken by ou:' FLOOR WARDENSG 1 e Lei S // f'./ y~ NAME OF FLOOR WAR EN CONTACTED FLOOR CHOSEN TELEPHONE NUMBER Does Floor Warden have knowledge of: A. Positio durin fire drill or emergency? B. Notificati procedures? C. Location alarm boxes? Yes ~ No~ Yes No ❑ Yes No ❑ N/A ❑ D. Evac n location? E. Evacuatio9 procedures? ua F. Number of its on floor? G. Examining for exits on floor? Yes No ❑ Yes LX No ❑ Yes No U Yeses No C __ H. Report' whether smoke or Fire? I. Duties of,9eput Fire Warden and Searchers? Tv. J. Were fireArills conducted? Yes U No ❑ Yes L±V No U I Yes i✓r No LI *K. Floor wardens in numerous floors properly trained? Yes No ❑ _ TOTAL (11) Section B: (II, III, IV) 8 or mor,pp ered "NO" in Section B falls. SECTION B TOTAL (36) Number of correct answers in this section is j_ ... , of incorrect answers is . Number of N/A answers is _______ M25.14 15.670250.3-fi 25-P t

NYC-WTC 000166310