NYC-WTC_000166105

NYC 9/11 Public Portal Document

Instructions to Inspectors ooxes this form must have an answer. raven th 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--OF 1 E r Z 01 1- ! 1~ - Inspector

Name of Candidate O5 _P PiVc name) fl (Print last name, fi oe Address Q of Examination // / i g r A: Instructions to Inspectors—it any asterisk (*) items are marked "NO", terminate the test immediately. See Section Vlll for YES NO N/A further information. I. Physical Requirements—Does candidate have ability to: *A. Speak nd understand English? * B. Hear spoken words over a telephone? * C. Possess necessary vision? (wit.~j rrective devices) (eorr a devices acceptable) Yeti ,L No ❑ YesAL No ❑ Yes tg No ❑ B: 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 ri records current? v. B. Firemen's Service Elevator Test Records current?J v. C. Keys k t at Fire Command Station Yes L. No El Yes No ❑ N/A El J Yes No ❑ N/A ❑ v. D. Fire afety Plan and building floc . E. A current list of all floor Wardens and phone( v. F Master window keys available? plan Fire Command Station? num, s at Fire Command Station? Yes No O Yes No ❑ Yes ❑ No U N/A v. G. BuiidLng 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. Ill, a. Specific Building Inspection: Special Instructions—Choose one floor for the general floor inspection FLOOR Building Inspection—Signs and Charts— v. A. Ar st 'rways roperly lettered? v. B. Are floors properly numbered? v. C. Is floor diagram sted? YesTL No Yes No El Yes E No v. D. Are thairways re-entry V. E. Are elevators properly lettered on each v. F. Is floor diagram properly oriented? sjgg posted? elevator bank? Yes ' No 0 N/A ❑ Yes ❑ No N/A ❑ Yes ❑ No v. G. Is levator sign "in Case of Fire, v. H. re exit doors unlocked, closed and v. I. Fire Dril Organization Charts Use Stairs' posted? unobstructed? posted and current? Yes ❑ No N/A ❑ Yes No ❑ Yes No ❑ TOTAL (9) Ill. b. Building Inspection—Signs and Charts—Choose one floor for the general floor inspection FLOOR v. A. Are stairways properly lettered? v. B. Are floors property numbered? v. C. Is floor diagram posted? Yes No ❑ Yes No ❑ Yes _ No ❑ v. D. Are airways re-entry v. E. Are elevators properly lettered on each v. F. Is floor die ram property oriented? SØ' posted? eievat bank? YesL No NIA❑ Yes No❑ N/A❑ Yest t NoEl v. G. is levator sign "in Case of Fire, v. H. Are exit doors unlocked, closed and v. if Fire Drill Organization Charts Use S irs" posted? unob ructed? post and current? Yes No ❑ N/A ❑ YesJ. 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 taken by you:' 1 FLOOR WARDENS: 1 d_n) NAME OF RW R N CONTACTED FLOOR C OSEN TELEPHONE NUMBER I Does Floor Warden have knowledge of: A. Pos' 'o during fire drill or emergency? B. Notific ion procedures? C. Locaijn of alarm boxes? Yes L1 No Yes No ❑ Yes LX No ❑ N/A ❑ D. Evac tion location? E. Evaqytlon procedures? F. Numf of exits on floor? G. Examining for exits on floor? Yes No ❑ Yes No ❑ Yes No ❑ Ye No ❑ H. Reporting whether smoke or Fire? I. Duties f Deputy Fire Warden and Searchers? v. J. Were fire drills conducted? Yes No ❑ Yes No U Yes l No ❑ *K. Floor wardens in numerous floors property trained? Yes O No ❑ TOTAL (11) Section B: (Ii, Ill, IV) 8 or morea,swered "NO" in Section B fails. SECTION B TOTAL (36) Number of correct answers in this section is J . Number of incorrect answers is . Number of N/A answers is M25•I4 1&8702503 R25 -P

NYC-WTC 000166182