NYC-WTC_000166105

NYC 9/11 Public Portal Document

Instructions to Inspectors—All box, n this form must have an answer. Answe 11th a "NO" answers to a "V" mandate a Violation Order, "NO" answers to a "*" mandate automatic failure. Check "YES" "N©" o' ••N/a'.

ON SITE EXAM FOR FIRE SAFETY DIRECTORR-OFF CE Z 01 Inspector_/!► Name of Candidate~ Es ` 111 Office Address ~_ _-_-~Daie of Examination ~~ (Print la name, first name) A: Instructions to Inspectors—If any asterisk (*) items are marked "NO", terminate the test Immediately. See Section Vlll for YES NO N/A further Information. 1. Physical R uirements—does candidate have ability I" *A. Speak nd understand English?

Yes B: Buildina No ❑ *B. Hear sp en words over a telephone? (with Tractive devices) Y No ❑ *C. Possess essary vision? (correc a devices acceptable) Yo No ❑

Instructions to Inspector—If any violation (V) Items are marked "NO", issue a Violation Order at the end of the Test. Test must uiiiiiiiuiu proceed. II. Records: v. A. Fire dr' records current? v. B. Fire en's Service Elevator Test Records current? v. C. Keys pt at Fire Command Station Yes _J Yes No ❑ N/A ❑ Ye No ❑ N/A ❑ v. D. Fire Safq1 Plan and building flop v. E. A current Jistof all floor Wardens and phon v. F. Master win id keys available? plan ire Command Station? number at Fire Command Station? Yes 111 No El Yes No El Yes No [I] N/A❑ v. G. Building current in actual Fire Drills? (*if over 3 months) Y 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. III. a. Specific Building Inspection: / C~ Special Instructions—Choose one floor for the general floor inspection BuIlding I ection—Signs and Charts— FLOOR v. A. Are st ays ~roperiy lettered? v. B. po properly numbered? v. C. Is fi diagram sled? Ye fQo J Yes No ❑ Y~❑ No v. D. Are st rways re-entry v. E. Are evators properly lettered on each v. F. Is floor diagath properly oriented? si posted? fvator bank? Yes No N/A El Yes El No El N/ Yes No ❑ v. G. Is eleva r sign "In Case of Fire, v. H. Are a doors unlocked, closed and v. I. Fire Drii rqanization Charts Use S irs" posted? u structed? pos and current? Ye No Li N/A Li ies❑ No s❑ No Li TOTAL (9) Ill. b. Building I pection--Signs and Charts—Choose one floor for the general floor inspection

v. A. Ares rways properly lettered? v. B. Are rs properly numbered? v. C. Is~Ilo agram posted? i Ye Nom Ye_s ❑ No ❑ eYs LJ No ❑ v. D. Are star ys re-entry v. E. Are a rs properly lettered on each V. F. Is floor d' am properly oriented? si ns sle d? elev ler bank? ~ Yes No ❑ /A ❑ es ❑ No_❑ N/A ❑ v! 1 No LI v. G. s elevator 'gn "In Case of Fire, v. H. Are exit do unlocked, closed and v. I. Fire Drill Organization Charts Use Sta' ' posted? unobstr ed? posted and cuuent? Yes No ❑ N/A ❑ Y No ❑ Yos No n 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:

NAME OF FLOOR WAR CONTACTED FLOOR CHOSEN TELEPHONE NUMBER Does Floor en have knowledge A. Posit Burin fire drill or emergency? B. Notific n procedures? C. Location alarm boxes? Yes AleU Yes' No ❑ YestI No El . N/A❑ _ D. Evacj, jø1 location? E. Evac i6n procedures? JF. Number exits on floor? G. Exa n ar ng for exits on floor? Yes Y No U Yes 1_ No ❑ Yes ❑ No ❑ H. Repo Y tr' whether smoke or Fire? No ❑ I. Duties oPepuy Ye No L Wardenytd Searchers? v. J. Were fi rills conducted? 3 Y No ❑ * K. Floor wardens in numerous floors properly trained? Yes Lif Fire;Z7 TOTAL (11) Section B: (II, III, 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 M25.14 16.870250.3•R25-P

NYC-WTC 000166314