Investigation of Complaint Report Form, n.d.

NYC 9/11 Public Portal Document I For E U. Use Only: FP1MS Data J . I Initials LLLI UNIT PHONE #JCl!3

1“ VIOLAnOHHO. JI 1 W312 Z II I i~i 11111111 Responder* is: □ owner ^H^anaging agent ^tenant □ city agency □ daycare center

Place of Occurrence (P >) Street Number 1111 1 1 17t Prefix! 1 1 Street Name WTICJ 1 1[ U I I II I I I 1 I Suffix 11 I Zip Code It lol^l*il^ 1 t It 1^141 Boro Code Type I 1=Man; 2»Bx; 3=SI; 4-Bklyn; 5=Qns

AKA I J I I I I 1,1 I I I I I I I I I I I I I I I I N I I I I I I I MalHng Address (if different frorn premisei address) Street Number 11,1 111 11 Prefix 1 1 1 Street Name L_i I M I I I I I I I I J: suffix LLl Zip codbl 1 I I h l - LLU Type [ Boro Code 1=Man; 2=8x; 3>St; 4sBldyn: 5>Qns: 6=Out of City

Addjnto I I II II I I I I I I II I III I I I I I I II 111 I I I LI Notice of Violalion and amSer Nr Correct and Certify Correction: PLEASE TAKE NOTICE that the premises cited above is in viol^ion of ((le requirements of law. It is further ORDERED by the FIRE COMMISSIONER that these violations be correctedandcertifiedtobeincompli4ewithff(4q^'>ferfferitsotlawwithftii6daysof the date of issuance. Certification must bemadBontheCertiticate of Correction (Gold Copy). The Certificate oMorrectioh and all proof of compliance MUST BE R^EIVED by theRureau of Qie Prevention, Enforcement,Unif, S UerrSTech Ess’,. Brooklyn. New York 11201-3857 (718) 999-2392 by Close of business on |O^ | XH I lEaimfcfcii I F'fS* offenders who properly certify correctidn shall avoid a hearing and ^aHV- All other respondents must appear at the Environmetital Control Board (ECB) hearing indicated below. Notice of Hearing: If the Certificate of ^rrection IS NOT RECEIVED Sy the dale indicated above OR if no date is indicated above, the respondent MUST APPEAR at a hearing on at ®:30am, □ 10:30am, Di:30pm, □3:00Dm at the ECB Hearing Office located in □Brooklyn OManhmtan nOueeoS □ Staten Island. □ Bronx. (The address foreach locatw is provided on the reverse side of this form.) Tfxs hearing is your opportunity to answer and defend the allagations^t forth belos^' If you do not appear, you will be held in defautt and subject to maximum penalties. V ' REPEAT OFFENDERS MUST appear at the hearing on the scheduled date. Upon investigation, it has been determined by the above named Petitioner that there is reasonable cause to believe that the above named Respondent is in violation of the Administrative Code andtor Fire Department Rule(s), “3 RCNY §§16-01, 16-02, 16-03;" Rule1 BucheU andtor Fjre Extinguishers Rule 17 CerttPcales of Fttnees Q Fatted to provide .~wr approved, operathte^re extinguishers filled with (sand/water) and/or □ Failed to (obtain/provide) a (Certificate of FitnessfCertificate Molder on Duty) for LOCATION Rule 2 Waste Receptacles ^e18 CertifIcalM of ApprovaVCtoaliftcattoo/Llconse I2J Failed to provide__ ; approved receptacles for waste at Q Failed to (obtain/provide) a Certificato of (Approval/Qualification/License) NUMBER _________________ as required. for _____________________ . __ ________ ______ _______ _ as required. SPECIFY

Rule 3 Mo Permit Rule 19 Certificate of OccupancyrPubBcAa^mblyPmirtflfAffidsvits/Documentation/ □ (SoldZStored/Used/Manufactured/Transported) (combustibtes/Hammablesy explosives) without required valid permit. □ Ptasw/Applicaitons Failed to provide (or __ ----- 5pf5iF Rules QuantHles In Eacassl of Permit □ (Sold/Stored/UsedZManufacturedZTransported) of_^______ / in eicess Of amount stated pn permit. Rule 20 Q _ ________ from SIQNAIOTY .as required.

Failed to conduct required (equipmentAystem) (test/inspection) of

I : Rule 5 Q Produce Permit and/or Record Failed to produce lpermit/record) regarding Rule 21 _ __________________________________________________ as required. Containers SPECIFY

OESCRIPTWN ■ al -■ ■ -.-r-t- ■ _______as required. f I Failed Io provide approved containers for. SPBCirY LOCATION ‘' as required. Rule 6 Rule 22 Ibnks/Supports _ □ Failed to provide (Sigo^Postings/lns1ructions) for at _________ _____ i____________ ______ ____ LOCATION as required. □ Failed to (provide/maintain) approved tanics/supports for as required SPeciFv

Rule 23 Storage Rule 7 Labels/Marics/Stamps □ Failed to provide (Labels/Marks/Stamps) for at_______________ _______________________ LOCATION aS required. I I ' Failed to provide (vaults/cabinets/room/area) for the storage of

Rule 24 Racks as required.

I I Failed to provide appropriate racks at Obetructlons/Accomulattona location astequired. 1^^ to mn^ alti (obsthjctions/accumulations of rubbish or storage) of iWfc .Okswfc^ i« : from f________ as required. electrical equipment as required. Rule 9 Adequato Egreas/Aisle SpaceKaearsnce Rule 26 Apgrauad ReMgMadoiVHeaHng Devices or Untts Failed to provide adequate (egres^aisle space/clearance) at : : Q Failed to (providetoratect/maintain) _____------- ---- —-------------------- _ ________________ ______ ..... ______________ __ as required. ■ (refrigoration/heatino) devicos as reqMMdT "" : TBESTi® Rule 10 Operating Contrary to C of O Rule 27 Approve UghUng Devices □ Opersaed .contrary to the certificate of occuparwy. [~~| Failed to (orovide/pfQtect/maintainl _______________ ; ^CIFY lighting_devices as reqixred. Specify typa of protectiott’required' Rula 11 aeneretl 4- □ Failed to maintain condition as required: ______________ in a proper Rule 28 Exposed Hames or Spmta □ (Unlawfully allowadrtailod to protect) exptwed flame or spark at Rule 12 Malrrtenance of Sprinkler, ^tandpipe, Alarm, Buppiesston SysNms _______ ■__ ■___ __ ____________________________________ as requited. ' rj Failed to property (pnovid^rrtaintain) system or part thereof LOCATION ■aiRirr Rule 29 DMivnaled Arses as required . Dascribo below Q Failed to (provide/maintain) designated area/premises for Rule 13 FirsR □ Failed to ।provfdttffrtaiwain ncn-combustiWe at ' - Or provide affadavit that corf material Rule M HmSaNty InOmee auarilMtNfHMMsAIMeie .as required.

has been yfbhNt. retardant as required. rn Failed to comply with the lire sadMy requirements for (office buHdings/, Rule 14 Fkeproef hotels/motets). Specify: _______ _____________ Q Failed to ( rttain) (self-closing fireproof doors/windows) at _ aS required. Repeat Violeflon (115-229)

Rule 15 Fireproof Pi I I ts or Walls ,r. . -

Failed to (provide/maintain) fireproof partitions or walls at □ Faitod lo correct Rule(s) # _ _______ _ ______ as previously cited On NOV (Respondent must appear at the httarifig.) as required. False CertHlcatlon (§15-220.1) Rule 16 Vsntitelion Q " . .......... .. loca/ion

Failed to provide (approved vents/adequate ventilation) at .□ Willfully falsified Certificate of Correction for NOV ». (Respondent must appear at hearing.) _i^tequired. Q OtIwr Code Sectlon/Rule Describe offense below. •/ SPECIFY SECTION

Description of Violation: yf A ■ • Aril__ fiaA, talite 'V A^c. W ton. K i •» *“*■ A___ B C /** f K___ 4^ tr \ ______ _________________

I personally (Aserved the commission of the above offjfeqjsTor personally reviewed The o(fice rbcti4 indicat^'the oftense(s).ctoroed above. All statements made herein are affirmed under penalty of perjury. Date of Ojffense:

INSPECTOR'rSWlNAirUBe i r Inspector's Rn Refiaby Numbeii PH PRINT NAME , J

M25-ia MI-SimMI-112 AFFIDAVIT (CERTIFICATE) OF SERVICE (COMPLETE REVERSE SIDE) ■'5. ISSUING UNIT’S COPY

NYC-WTC_000169184