NYC-WTC_000166105

NYC 9/11 Public Portal Document

Instructions to Inspectors—All boxes o jis form must have an answer. Answers w a "NO" answers to a "V" mandate a Violation Oroer, "NO" answers to a "*" mandate automatic failure. Check "YES" "NO" c, "N/A' , ON SITE EXAM FOR FIRE SAFETY DIF:ECTOR--OFF CE Z 1 Inspector Name of Candidate ' l .E 1 / .2 'D Office Address— / Date of Examination >, 1 (Print last name first name) O

Instructions to Inspectors—if any asterisk (*) items are marked "NO", terminate the test immediately. See Section VIII for YES NO N/A further information. , _---- _L!!ysica1 Re ui ments—Does candidate have ability to: *A. Speak and nderstand English? * B. Hear spoke ords over a telephone? *C. Possess neçe ry vision? I (with corn live devices) (corr e devices acceptable) Yes No ❑ Yes No ❑ Ye No 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. II. Records: v. A. Fire dr' records current? v. B. Firemen's Service Elevator Test Records current? v. C. Keys ke at Fire Command Station. Yes No❑ Yes❑ No❑ N/A❑ Yes 7No❑ N/A [I v. D. Fire 7Safe Pla— nand building floo v. E. A current t of all floor Wardens and phon v. F. Master window keys available? plan ommand Station? numbe t Fire Command Station? Yes ❑ Yes o❑ Yes [1 No Li N/A v. G. Building current in actual Fire Drills? ( * tf over 3 months) Yes [1 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: Special Instructions—Choose one floor for the general floor inspection-___ Build~glI, nspection—Signs and Charts— FLOOR v. A. Are ys roperly lettered? v. B. Are fro properly numbered? v. C. Is fl gram osted? Y o Yes No ❑ Yes No ~ v. D. A ays re-entry v. E. Are elevat properly lettered on each v. F. Is flo~di ram properly oriented? ^~ s Vnposted? elevato ank. Yes ❑ N/A❑ Yes Li No❑ N/A [II Yes o❑ J v. G. Is elevator,ign "In Case of Fire, v. H. Are exit do unlocked, closed and v. I. Fire Drill Organization Charts Use St s" posted? unobstr ed? posted current? Yes No ❑ NIA ❑ Yes. ] No ❑ YestJ No Ii TOTAL (9) III. b. Building Inspection—Signs and Charts—Choose one floor for the general floor inspection _. - , FLOOR v. A. Are staff ays properly lettered? v. B. Are floor roperly numbered? v. C. Is floor di am posted? Yes No ❑ Yes No ❑ Yes NoLI v. D. Are st 4i ays re-entry v. E. Are elevato property lettered on each v. F. Is floor di am properly oriented? si posted? elevator nk? Yes .C J No ❑ N/A ❑ Yes- 1 No L) N/A [ I Yes❑ No ❑ — L v. G. Is elevator s'gn "In Case of Fire, v. H. Are exit doors unlocked, closed and v. I. Fire Drill Organization Charts Use Stair ' posted? unobstruct ? posted and current? Yes No ❑ N/A ❑ Yes No ❑ Yes o❑ 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 9(/ be taken by yo FOR WA

NAME OF FLOOR WARDEN CTED FLOOR CHOSEN TELEPHONE NUMBER Does Floor arden have knowled a of: A. Positio uring fire drill or emergency? B. Notifical' procedures? C. Locatio alarm boxes? Yes ilo Yes Q No ❑ Yes ! No ❑ N/A ❑ D. Evacua " n location? E. Evacu • n procedures? F. Num' ~noof exits on floor? G. Examinin r exits on floor? Yes No ❑ Yes No ~~ Yes LJ No ❑ Yes - No ❑ _ ~_ __ H. Reporrti whether smoke or Fire? I. Duties o eput Fire Warden and Searchers? v. J. Were f' rills conducted? Yes,t~ No ❑ Ye No ~s _ Yew I No ❑ __ ~_ *K. Floor wardens in numerous floors properly trained? Yep No [I

Section B: (II, III, IV) 8 or more answered "NO" In Section B falls. TOTAL (11) SECTION B TOTAL (36) 77 Number of correct answers in this section is Number of incorrect answers is . Number of N/A answers is M25-14 166702503P25-P

NYC-WTC 000166322