NYC-WTC_000166105

NYC 9/11 Public Portal Document

Instructions to Inspectors—All boz. . on this form must have an answer. Answe. with a "NO" answers to a "V" mandate a Violation Order, "NO" answers to a "s" mandate automatic failure. Check "YES" "NO" or "N/A". ON SITE EXAM FOR FIRE SAFETY DIRECTOR-OFFICE Z 01 __ Inspector ~~~_ Name of Candidate Imo- -.Ip CCO.. Office Address r 7 "" (~-- Date of Examination / / 3 (Print last name, first name) 'o A: 7 `V'/_

Instructions to inspectors—If any asterisk (*) Items are marked "NO", terminate the test immediately. See Section VIII for YES NO N/A further Information. 1. Physical Requirements—Does candidate have ability to: __ _ *A. Speak and jmderstand English? *B. Hear spoken words over a telephone? *C. Possess necessary vision? (with,, gec1ie devices) (corrective devices acceptable) Yes No ❑ Yes 0 Yes o❑ 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 ords current? v. B. F,rempg Service Elevator Test Records current? v. C. Keys ke Fire Command Station Yes j,K No Yes No❑ N/A ❑ Yeg-t1 N/A Li 3 v. D. Fire Safety PI and building floc v. E. A currentjst of all floor Wardens and phonel v. F. Master window keys available? plan at Fir ommand Station? numb at Fire Command Station? Yes No❑ Yes J No❑ Yes [1 No❑ N/ v. G. Building current in actual Fire Drills? *if over 3 months) YesI No ❑ TOTAL (7) Instructions to inspector—ti any violation (V) Items are marked "NO", Issue a Violation Order at the end of the Test. Test must Proceed. 111. a. Specific Building Inspection: Special Instructions—Choose one floor for the general floor inspection '7 ' Building Inspection—Signs and Charts— FLOOR v. A. Are pays properly lettered? v. B. Are flools.pfoperly numbered? v. C. Is floor di m sted? Ye No [] Yes'e No ❑ Ye No ~_ v. D. Are stairways re-entry v. E. Are elevators properly lettered on each v. F. Is floor diagram properly oriented? sign 'w ed? elevattor b -,-- Yest~J No❑ N/A❑ YesD NoD N/A❑ Y o❑ v. G. Is elevator sign "in Case of Fire, v. H. Are exit doors unlocked, closed and v. 1. Fire Drill Qiganization Charts Use Stairs': posted? unob po nd current? Yes No ❑ N/A ❑ Yes ❑ es ❑ No ❑ TOTAL (9) 111. b. Building Inspection—Signs and Charts—Choose one floor for the general floor inspection LOOR v. A. Are stairvyFyrs properly lettered? v. B. Are floors properly numbered? v. C. Is floor ram posted? Yes 1 No ❑ Yes . No ❑ Yes No ❑ v. D. Are irways re-entry _v.E.Areelevatorsproperlyletteredoneach V. F. Is floor diagram property oriented? si n ? elevator bank? 17 Yes No❑ N/A❑ Ye No❑ N/A❑ Ye No❑ v. G. Is elevator sign "In Case of Fire, v. H. Are exit doors unlocked, closed and v. I. Fire Drill Organization Charts Use Stai ed? unob ed? post nd current? Yes No❑ N/A❑ YeUNo❑ Yes NoM 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:

NAME OF FLOOR WARDEN CONTACTED FLOOR CHOSEN TELEPHONE NUMBER Does Floor Warden have knowledge of: A. Position durin fire drill or emergency? B. Notification procedures? C. Location of alarm boxes? Yes❑ No _ Yes❑ No❑ Yes❑ No❑ N/A❑ D. Evacuation location? E. Evacuation procedures? F. Number of exits on floor? G. Examining for exits on floor? Yes ❑ No 0 Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No ❑ H. Reporting whether smoke or Fire? 1. Duties of Depu Fire Warden and Searchers? v. J. Were fire drills conducted? Yes❑ No❑ Yes❑ No~ _ Yes❑ No❑ _ * K. Floor wardens in numerous floors properly trained? Yes ❑ No ❑ TOTAL (11) Section B: (II, 111, 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 M2S14 ,6g7p296.3-R2SP

NYC-WTC 000166194