NYC-WTC_000166105

NYC 9/11 Public Portal Document

Instructions to Inspectors—All boxes this form must have an answer. Answers i a "NO" answers to a "V" mandate a Violation Order, "NO" answers to a "*" mandate autom.tic failure. Check ' YES' "NO' cr 'N,A. ON SITE EXAM FOR FIRE SAFETY DIRECTORj_ O CE ! Z 01 Inspector "'_'_ !~ Name of Candidate / ' ` 14 j-~fIjl l` , Office Address ~Z~ .i1 to of Examination / ~Y (Print last name, first name) _

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 erstand English? *B. Hear spoke orris over a telephone? I C. Possess necessary vision? (with co five devices) (correctiv evices acceptable) Yes - No ❑ Y No ❑ No ❑ B: Buildings Instructions to Inspector—If any violation (V) Items are marked "NO", issue a Violation Order at the end of the Test. Test must proceed. 11. Records: v. A. Fire i1 r cords current? v. B. Fireme ' Service Elevator Test Records current?f V. C. Keys k at Fire Command Station. Yes No ❑ Yes 4 J No ❑ N/A ❑ Ye No ❑ N/A ❑ v. D. Fire S1'ety,,PIan and building floo v. E. A current I' of all floor Wardens and phon v. F. Master wi keys available? plan at F' a Command Station? numbe at Fire Command Station? Yes No ❑ Yes _No ❑ Yes No ~~ N/A V. G. Buil ng current in actual Fire Drills? (*if over 3 months) r~ 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 ç ..._ 7' Proceed. Ill. a. Specific Building Inspection: Special Instructions—Choose one floor for the general floor inspection_ ._ Building Inspection—Signs and Charts-- OOR v. A. Arestairways operly lettered? v. B. Are rfl properly numbered? v. C. Is flocr i gram posted? Yes o f Yes'U No ❑ Ye No ❑ v. D. Are spWvays re-entry v. E. Are elev s properly lettered on each v. F. Is floor diagram properly oriented? si posted? elev bank? Yes J No El, N/A ❑ Y No ❑ N/A ❑ Ye No_❑ v. G. Is elevato Ign "In Case of Fire, v. H. Are exit d09rs unlocked, closed and v. I. Firo Drill Organization Charts Use St s" posted? unobstr ed? posted and current? YesXJ No ❑ N/A ❑ Yes≥J No ❑ Ye No ❑ TOTAL (9) Ill. b. Building Inspection—Signs and Charts—Choose one floor for the general floor inspection . FLOG v. A. Are St ays properly lettered? v. B. Are fro _K_,~_ro_perlynumbered? v. C. Is floor d am posted? Yes o❑ _ oLII _ Ye No El _ v. D. Are st ays re-entry v. E. Are elev s properly lettered on each v. F. Is floor di m proporly oriented? si n osted? alevat ank~ Yes No❑ N/A❑ Ye No❑ NIA❑, No❑ v. G. Is elevator s' "in Case of Fire, v. H. Are exit d s unlocked, closed and v. 1. Fire Drill Orga ' ion Charts Use Stair " posted? unobst ed? posted an Trent? Yes No❑ N/A❑ Y No❑ YS 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-~'ln the event of a fire on this floor, explain which specific actions must be taken by you." FLOOR WARD

NAME OF FLOOR WARDEN CON (o FLOOR CHOSEN TELEPHONE NUMBER Does Floor Warden have knowledge of: A. Position d fire drill or emergency? B. Notifi jjoa procedures? J C. Locatro f alarm boxes? Yes No ~Ces Li No ❑ Ye≤ LJ No ❑ N/A ❑ D. Evacuati ovation? E. Eva n"procedures? F. Number its on floor? G. Examini ac i o exits on floor? Yes f No ❑ s El No ❑ Yes No ❑ Yes-t[ No ❑ H. Reportingwhether smoke or Fire? I. Duties of put Fire Warden and Searchers? v. J. Werefire Its conducted? Yes No ❑ Yes No Yes-iT No ❑ *K. Floor wardens in numerous floors properly trained? Yes I_I o [_I TOTAL (11) Section B: (II, 111, IV) 8 or more answered "NO" in Section B falls. SECTION B TOTAL (36) Number of correct answers in this section is Number of incorrect answers is . Number of N/A answers is M2 -l4 16-8r02501R25-P

NYC-WTC 000166312