NYC-WTC_000166105

NYC 9/11 Public Portal Document

Instructions to Inspectors—All boxes on this form must nave an answer. Answers with a "NO" answers to a "V" mandate a Violation Order, "NO" answers to a "" mandate automatic failure. Check "YES" ' or "N/A". ON SITE EXAM FOR FIRE SAFETY DIRECTOR-OFFICE Z 01 t2 i Inspector )f / Name of Candidate (Print last name, first name) Office Address 7. WD r lrteC~, 1 cis) ° C r aJExaminatio C I

A: NV ` '7 -

Instructions to Inspectors—It 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? * B. Hear spoken words over a telephone? *C. Possess necessary vision? (with corrective devices) (correct' devices acceptable) Yes No ❑ Yes No 0 YesJ No 0 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 drill records current? v. B. Firemen's Service Elevator Test Records current?l v. C. Keys Icapt at Fire Command Station. Yes No ❑ Yes No ❑ N/A ❑ Yes No 0 N/A ❑ v. D. Fire Safety Plan and building floo v. E. A current list of all floor Wardens and phonel v. I. Master window keys available? plan at 're Command Station? num rs at Fire Command Station? Yes No 0 Yes IQ No ❑ Yes ❑ No ❑ N/A v. G. Buildin current in actual Fire Drills? *if over 3 months Yes1 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{ FLOOR ~X Building Inspection—Signs and Charts— '• / ~~' v. A. Are stairways roperty lettered? v. B. Are fl rs properly numbered? V. C. Is floor diagram posted? Yes 4 No Yes No ❑ J Yes ❑ No. v. D. Are tairways re-entry v. E. Are elevators pro rly lettered on each T v. F. Is floor diagram properly oriented? si ns posted? elevato bank? Yes No ❑ N/A ❑ Yes No ❑ WA ❑ Yes No ❑ v. G. I elevator sign "In Case of Fire, v. H. Are exit doors unloc ed, closed and v. A. Fire Drill Organization Charts Use Stairs" posted? unobstructed? posted and current? Yes No ® N/A 0 Yes No ❑ Y No er TOTAL (9) Ill. b. Building Inspection—Signs and Charts—Choose one floor for the general floor inspection FL R v. A. Are stairways properly lettered? v. B. Are f29i properly numbered? v. C. Is fl diagram post Yes No ❑ Yes No ❑ Yes J No ❑ , v. D. Are tairways re-entry v. E. Are elevators properly lettered on each v. F. Is floor di ram properly rien ? Si fl posted? elevat bank? Yes kL. 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 and . ire Drill Organization Charts Use Stairs" posted? unobstructed? posted d current? Yes 0 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 be taken by you," FLOOR WARDENS: lac I re Cg 113 &-s- I 9, 2 3 NAME OF FLOOR WARDEN CONTACTED FLOOR CHOSEN TELEPHONE NUMBER Does Floor Warden have knowledge of: A. Positnn durin fire drill or emergency? B. Notific ion procedures? C. Location of alarm boxes? Yes No~ Yes No ❑ Ye No ❑ N/A ❑ D. Eva anon location? E. Evacuation pr ures? fF. Number of exits on floor? 'G. Fxamin' g for exits on floor? Yes No ❑ Yes No ❑ Yes No 0 Yes No ❑ H. Repo g whether smoke or Fire? I. Duties of Depu Fire Warden and Searchers? v. J. Wer f drills conducted? Yes bI. No 0 Yes No Yes No ❑__ * K. Floortwardens in numerous floors properly trained? YeLi No ❑ J_ TOTAL (11) Section B: (11, III, IV) 8 or more answered "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 M2Sta t66A2543R2SP '.3o

NYC-WTC 000166156