NYC 9/11 Public Portal Document
Instructions to Inspectors—All box^Bn this form must have an answer. Answ^Arith a “NO” answers to a “V” mandate a
Violatioi^Order, “NO” answers to a mandate aimmatic failure. Check “YES” “NO” or “N/A”.
ON SITE EXAM FOR
FIRE SAFETY DIRECTOR—OFFICE
Name of Candidate^
Z A, ClS'-01IX5? __ Inspector LA-Q 3)1
l(Pnnt last name, fir^ name)'
Office Address. '3471 /ivg. Date of Examination
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 and understand English? *B. Hear spoken words over a telephone? *C. Possess necessary vision?
(with^rrective devices) (correcUve devices acceptable)
Yes 15^ No □ Yes No □ Yes 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
I
proceed.
II. Records:
V. A. Fire drill records current? V. B. FiremanI’s Service Elevator Test Records current? v. C. Keys at Fire Command Station?
Yes [3 No □ Yes NoD N/A □” Yes No □ N/A □
V. D. Fire Safety Plan and building floor A current list of all floor Wardens and phone v. F. 'Master window keys available?
plan at Fire Command Station? nur at Fire Command Station?
Yes IX No □
V. G. Building current in actual Fire Drills?
Yes No □
(*if ov !r 3 months)
Yes'^/ No D
Yes □ No □
N/A^
A
TOTAL (7) 7 I
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:
3
Special Instructions—Choose one floor for the general floor inspection
Building Inspection—Signs and Charts—
V. A. Are irways goperly lettered? V. B. Are floors properly numbered?
FLOOR
V. C. Is f iagramposted?
X
Yes No Yes No □ Yes No □
V. D. Are stairways re-entry V. E. Are elevators properly lettered on each V. F. Is floor diagram property oriented?
si^s posted? bank?
Yes No □ N/A □ No □ N/A □ Yes'^ No □
V. G. Is elevator sign “In Case of Fire, 7 V. H. Are exit doors unlocked, closed and V. I. Fire Drill Organization Charts
Use S^rs” posted? unob^ucted? posted and current?
Yes lX No □ N/A □ Yes jZI No □ Yes □ No IX
T TOTAL (9)
III. b. Building Inspection—Signs and Charts—Choose one floor for the general floor inspection
FLOOR
V. A. Are sUirways properly lettered? V. B. Are floors properly numbered? V. C. Is floor diagram posted?
Yes No □ Yes No □ Yes'0 No □
V. D. Are stairways re-entry V. E. Are elevators properly lettered on each V. F. Is floor diagram properly oriented?
■sig^ posted? elevator bank?
Yes
V. G.
No □ N/A □
elevator sign “In Case of Fire,
Yes*gf No □ N/A □
V. H. Are exit doors unlocked, closed and
Yes^ No □
V. I. Fire Drill Organization Charts
Y
Use ” posted? unob^ucted? posted and current?
Yes 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
FLOOR WARDENS:
NAME OF FLOOR WXBDEN CONTACTED^
13__
FLOOR CHOSEN TELEPHONE NUMBER
Does Floor Warden have knowledge of:
A. Position during fire drill or emergency? I B. Notification procedures? C. Location of alarm boxes?
Yes'S? NoD I Yes SZ No □ Yes No □ ___________
N/A □
D. Evac^tion location? E. Eva tion procedures? F. Nurn^r of exits on floor? 'G. Examining for exits on floor?
Yes CS No □ Yes No □ Yesly NoD YesM No □
H. whether smoke or Fire? Duties of DepuN Fire Warden >and Searchers? V. J. Werejire drills conducted?
No □ Yes ® No U Yes^ No □
wardens in numerous floors properly trained? Yes No Q
TOTAL (11)
Section B: (II, 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
M25-14 16«TO50-3fl2S4"
NYC-WTC_000168921
OCR can misread numbers and units. Confirm readings against the page image before using them.