NYC-WTC_000166105

NYC 9/11 Public Portal Document

Instructions to Inspectors—All boxes c. .his form must have an answer. Answers A a "NO" answers to a "V" mandate a Violation Order, "NO" answers to a ""' mandate automatic failure. Check "YES" "NO" or "N/A". ON SITE EXAM FOR FIRE SAFETY DIRECTOR-OFFICE ,' ~9 ` Z te Inspector

Name of Candidate ' L ~~ " ~, (Print last name, first name) 4- S Office Address 7/ ~- Date of Examination S

Instructions to Inspector—If any asterisk (*) Items are marked "NO", terminate the test Immediately. See Section Vill 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) (corrective devices acceptable) Yes 1 No ❑ Yes No ❑ Yes 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. 11. Records: v. A. Fire dri records current? v. B. Firemen' -Service Elevator Test Records current v. C. Keys pi at Fire Command Station. Yes kJ No O Yes IJ No N/A❑ Yes D No N/A❑ v. D. Fire Safety Plan and building floo v. E. A current list of all floor Wardens and phonel v. F. Master window keys available? plan at a Command Station? num~bs Fire Command Station? Yes. No ❑ Yes L2J No O Yes ❑ No ❑ N/A v. G. Building current in actual Fire Drills? (*if over 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. III. a. Specific Building Inspection: Special Instructions—Choose one floor for the general floor inspection j~ FLOOR Building Inspection—Signs and Charts— v. A. Are stairways roperty lettered? v. B. Are floors properly numbered? v. C. Is floor gram-_posted? Yes e~ No YeO No O J Yes No lJ v. D. Are stairways re-entry v. E. Are elevators properly lettered on each v. F. Is floor di ram properly oriented? si,9~posted? elevato nk? Yes LJ No O N/A ❑ Yes No O N/A O Yes LJ No ❑_ v. G. Is elevator sign "in Case of Fire, v. H. Are exit doors unlocked, closed and J v. I. Fire Drill Organization Charts Use Stag " posted? unobst ed? posted current? 3 Yes 0No ❑ NIA ❑ Ye No O Y No TOTAL (9) III. b. Building Inspection—Signs and Charts—Choose one floor for the general floor inspection FL( )R v. A. Are sta' ways properly lettered? v. B. Are fiDo roperly numbered? v. C. Is floor diagram posted? Yes No ❑ Yes ]No ❑ I Yes. No ❑ v. D. Are stairways re-entry v. E. Are elevatprs properly lettered on each v. F. Is floor diagram properly oriented? si ns ed? elevato nk? Yes No N/A❑ Ye No N/A❑ Yes No❑ v. G. Is elevator sign "In Case of Fire, I v. H. Are exit doors unlocked, closed and v. I. Fire Drill Organization Charts Use posted? unobstructed? posted current? YesD No 0 N/A 0 Yes No 0 Yes tJ 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 4e1 ken by you.' FLOOR WARDENS: Jr /) r✓~ ✓`_ NAME OF FLOOR WARDEN CONTACTED FLOOR CHOSEN TELEPHONE NUMBER

Does Floor Warden have knowledge of: A. Positj2p..during fire drill or emergency? B. Notificati n procedures? C. Location_pt alarm boxes? Yes No Yes No U Yes J4 No ❑ N/A ❑ D. Evacuation location? E. Evacuation procedures? F. Num of exits on floor? G. Examining for exits on floor? Yes"❑ No ❑ Ye9TJ No ❑ YeyCJ No ❑ Ye No ❑ H. Re rti whether smoke or Fire? I. Dutie Dep Fire Warden and Searchers? v. J. Were fi ,drills conducted? Yesof No ❑ Ye No Ye No [1 *K. Floor wardens in numerous floors properly trained? Y No ❑ TOTAL (11) Section B: (II, Ill, IV) 8 or mo a red "NO" in Section B falls. SECTION B TOTAL (36) Number of correct answers in this section is J Number of incorrect answers is . Number of N/A answers is 025.14 ,68102561n25-

NYC-WTC 000166177