NYC-WTC_000166105

NYC 9/11 Public Portal Document

Instructions to Inspectors—All box on this form must have an answer. Anwwe with a "NO" answers to a "V" mandate a Violation Order, "NO" answers to a "*" mandate automatic failure. Check "YES" "NO" or "WA': ON SITE EXAM FOR ht FIRE SAFETY DIRECTOR-OFFICE Z 01 Inspector wiF n ~T A Name of Candidate W .~ f M S N }A N IEbffice Address 7 ' M 7 -y _1i A - Date of Examination v` 1 (Print last name, first name) A. N CfZN~R.-~ ~7

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 understand English? *a Hear spoken words over a telephone? *c• Possess necessary vision? (withcorrective devices) (corrective devices acceptable) r~ Yes 0 No ❑ Ye No ❑ Yes ' No LI B: Instructions to Inspector ny violation (V) items are marked "NO", issue a Violation Order at the a Test. Test must II. Records: V. A. Fire drill records current? v. B. Rreme ervice Elevator Test Records curre C. Keys kept at Fire Command Station. Yes O No O Yes No NIA® Yes❑ No❑ N/A❑ v. D. Fire Safety Plan and building flood V. E. A current list o Arden and phon v. F. Master window keys available? plan at Fire Command Station? numbers at Rr Station? Yes O No❑ Yes Yes No [I N/A O v. G. Building current in actual Fire Drills? * r 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 stairways roperly lettered? v. B. Are fl rs properly numbered? v. C. Is floor diagram-° ed? Yes Nob Yes No Yes NoU V. D. Ar stairways re-entry v E. Are elevators properly lettered on each v. F. Is floor diagram properly oriented? siggs posted? I elevator bank? Yes No ❑ N/A ❑ Yes No ❑ N/A ❑ Y No ❑ v. G. Is elevator sign "In Case of Fire, v. H. Are exit doors unlocked, closed and 1. Fire Drill Organization Charts Use irs" posted? I unobstructed? posted and current? Yes No ❑ N/A ❑ Yes No ❑ Ye No ❑ TOTAL (9) III. b. Building Inspection—Signs and Charts--Choose one floor for the general floor inspection _ FLOOR v. A. Are stairways properly lettered? v. B. Are fl rs properly numbered? _v. C. Is floor diagram posted? Yes No ❑ Yes No ❑ Ye No ❑ v. D. Are stairways re-entry v. E. Are elevators properly lettered on each v. F Is floor d1gram properly oriented? sigs posted? elevato ank? Yes No ❑ N/A ❑ Yes No ❑ N/A 0 Yes No ❑ v. G. Is elevator sign "in Case of Fire, Use Stairs" posted? Yes No O N/A ❑ j v. H. Are exit doors unlocked, closed and v. 1. Fire Drill Organization Charts unobstructed? Yes)2I No ❑ posted and current? 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: N / 2~L C O NAME OF OOR WARDEN CONTACTED FLOOR CHOSEN TELEPHONE NUMBER Does Floor Warden have knowledge of: A. Positi durina fire drill or emergency? I B. Notification procedures? FC. Location of alarm boxes? Yes No~ Yes 0 No O Yes 8' No O N/A ❑ D. Evacuation location? E. Evacu " procedures? F. Number of exits on floor? G. Jrfor exits on floor? Yes No ❑ Yes U H. Reportin whether smoke or Fire? 1 I. Duti No ❑ Dep Yea.O~ No 0 Fire Warden and Searchers? Yesr U No ❑ v. J. Were_ffi a drills conducted? 4. Yes No ❑ Yes No U8 Yes E7 No ❑ *K. Floor wardens in numerous floors properly trained? Y No ❑ TOTAL (11) Section B: (II, III, IV) 8 or more a red "NO" In Section B fails. SECTION B TOTAL (36) Number of correct answers in this section is . Number of incorrect answers is . Number of N/A answers is

NYC-WTC 000166127