NYC 9/11 Public Portal Document
Instructions to Inspectors—All boy||^n this form must have an answer. Answ^|^ith 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
Z 01 Inspector-^ 7~* M Z-4' 1/ € LL £• i i
Name of Candidate. KHiLLI PS Office Address. 7 |/V^/- 0 A 4? d CZ/jpate of Examination _____
(Print last name,"first name) , . ■
VHY y. US-vs
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 ar^ understand English? * B, Hear spol^ words over a telephone? * C. Possess necessary vision?
(with coKBctive devices) (correctiye^evices acceptable)
Yes E No □ Yes QZ No □ Yes Im No □
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.
11. Records:
V. A. Fire d^records current? V. B. Firemej Service Elevator Test Records current? v. C. Keys kept at Fire Command Station?
Yes 0 No □ Yes 0 No □ N/A □ Yes No □ N/A □
V. D. Fire Safety Plan and building floor V. E. A current list of all floor Wardens and phone) v. F. Master window keys available?
plan at Fire Command Station? numbe/^ at Fire Command Station?
Yes £3" No □ Yes 0 No □ Yes □ No □
N/A 0"^ /
V. G. Building current in actual Fire Drills? (*if over 3 months) Yes No D
_____________________________________________________________________________________________________ TOTAL (7) 77
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
Building Inspection—Signs and Charts—
FLOOR
zz_
V. A. Are ays goperly lettered? V. B. Are flqp/s properly numbered? V. C. Is flqqrdrdgramposted?
Yes No
V. D. Are stairways re-entry
Yes M No □
V. E. Are elevators properly lettered on each
Yes No □
V. F. Is floor diagram properly oriented?
3
si^s posted? > elevator b^nlIk?
Yes □ No □ N/A EZ Yes IZ Ni No □ N/A □ Yes 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 Stajr^” posted? unobstrodted? posted and current?
Yes QZ No □ N/A □ Yes M No □ Yes Em No D 3
TOTAL (9) /
III. b. Building Inspection—Signs and Charts—Choose one tloor for the general floor inspection
FLOOR
V. A. Are stainvays properly lettered? V. B. Are floors-pfdperly numbered? V. C. Is floor diagram posted?
Yes [El No □ YesEEK NoD Yes 0" No □ 3
V. D. Are stairways re-entry Y- E . Are elevators properly lettered on each V. F. Is floor diagram properly oriented?
si^s posted? elevator hahk? _
Yes □ No □ N/A (2^ Yes iu No □ N/A □ Yes 13^0 □ /
V. G. Is elevator sign “In Case of Fire, V. H. Are exit doors unlocked, closed and V. I. Fire Drill Organization Charts
Use Stairs^ posted? unobstructed? posted apeTcurrent?
Yes Hr No □ N/A □ Yes Im No □ Yes M No □ 3
_________________________________________________________________________________ ____________________ TOTAL (9)
IV. Instructions to Inspector—If four (4) or more items below are marked “NO”, the inspector must issue a Violation Order at
4
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
FLOOR WARDENS: be taken by you.
3^ 73
- fl Sr p! PS
NAME OF FLOOR WARDEN CONTACTED FLOOR CHOSEN TELEPHONE NUMBER
Does Floor Warden have knowledge of:
A. Position^ring fire drill or emergency? B. Notification procedures? C. Location qf^lafm boxes?
Yes (M 1^ LD yes ikr h Yes EZL^o □ N/A □ 3
D. Evacuatipd location? E. Evacuatii "procedures? F. Number Lexits on floor? G. Examinin^Jef exits on tloor?
Yes No □
H. Reporting^hether smoke or Fire?
Yes No □ Yes No □
I. Duties okDeputy Fire Warden and Searchers?
Yes [3^Mo □
V. J. Werehre>drills conducted?
'4;
Yes 53 No □ Yes Im No U Yes No □
3.
* K. Floor wardens in numerous floors properly trained? Yes M No □ /i ; Z? ■ ___________________ /
TOTAL (11) //
Section B: (II, III, IV) 8 or more answered “NO” in Section B fails. SECTION B TOTAL (36) 33
Number of correct answers in this section is 3 Number of incorrect answers is Number of N/A answers is
25-14 16-870250-3-R25-P
NYC-WTC_000168818
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