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Home My WebLink About0067 SHADY LANE - Health 67 SHADY LANE, HYANNIS A= I o e it f I TO OF BARNSTABLE y LOCATIONCOI 511OL4 SEWAGE # VILLAGE ASSESSOR'S MAP & LOT�� INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) (size) NO.OF BEDROOMS BUILDER OR OWNER 161 PERMITDATE: COMPLIANCE DATE: Separation Distance.Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by . -w. `ter` � ` �� "� r once ,Y �' ,�a i �� encf i F �i �� DN�k , . e ..� j .� -4 ,&, Sewage Permit No. Mr # 105 rar Rd. Hyannis Ma. Village: � �� 6P_/�7 Installer's Name & Address Richard Hughes 140m DavisvillE' E. Falmouth, Ma. 02536 Builder's Name & Address Leevi Vahakangas 80 Sumi Rd. Hyannis Ma. Date Permit Issued 5'A 4&Z, Date Compliance Issued 6 /;y • �y,/� , ,/L✓/fps R rN (/\] i- E � No. d b5 Fee � THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS ftpYication for Misposai *pstem Construction permit Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon(A ❑Complete System ❑Individual Components Location Address or Lot No. f �� ^WNv Owner's Name,Address,and Tel.No. Assessor's Map/Parcel b T19 1 C3UaJY�U4J Installer's Name,Address,and Tel. o. Designer's Name,Address,and Tel.No. Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the En ronmental Code to lace th ystem in operation until a Certificate of Compliance has been issued by this Board o -It- t Signed / Date 3 Application Approved by Date 3 Application Disapproved by Date for the following reasons Permit No. 0 1 t Date Issued >— — ..'. r. In. ,r • r : .A. i .. . A 'Yr,in • 1 • . 1S!k 4� C Nok•.� 0 I'— b' Fee,it v x ,:.yo:ra. . THE COMMONWEALTH OF MA A HU ETT S Entered in computer: SS C S Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS �/ ftplitatlon for -MispoSal 6pstem Construction Vermit Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon(X ❑Complete System ❑Individual Components Location Address or Lot No. /�fj/ Lam,. �//�n/Ni�` Owner's Name,Address,and Tel.No. Assessor's Map/Parcel �•�r� Installer's Name,Address,and Tel. 'o. S Designer's Name,Address,and Tel.No. J Type of Building: Dwelling. No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) i Other Fixtures Design Flow(min.required) N gpd Design flow provided gpd Plan ' Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs ofjA#eiationsj(Ariswer when applicable) + G Date last inspected: Agreement: ,. The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the rivironmental Code and--. to place thersystem in operation until a Certificate of Compliance has been issued by this Board o ✓ea'1 h. Signed l Date Applicatibn Approved by s Date f, Application Disapproved by Date for the following reasons Permit No. a 0 — D Date Issued THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) _ Repaired( ) Upgraded( ) Abandoned by �. _ /l V A-0 62,wl d at `7 5� T •( �y�/Jt1�l S 1I'.�� has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. dated Installer Designer li #bedrooms �✓� Approved design flow IA gpd The issuance of this permi shall not be construed as a guarantee that the system will ctio. as desig ed. Date _ ! I - Inspector ✓-1 No. 'I _ �7CIf Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS Misposal *pstem Construction i3ermit Permission is hereby granted to Construct( ) Repair( /) Upgrade( ) Abandon( ) 3 System located at / jJ/� )�A/� �/1//xAJw/S, I and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with j Title 5 and the following local provisions or special conditions. Provided:Construction must be completed within three years of the date of this permi. Date �— — I 1 Approved by TOWN OF BARNSTABLE LOCATION SEWAGE # VILLAGE d0 x/it- �3 p /q� ASSESSOR'S MAP 6z LOT �I — I INSTALLER'S NAME It PHONE SEPTIC TANK CAPACITY G1 lJ ,o LEACHING FACILITY:(type) ( (size) JJ NO. OF BEDROOMS 3 PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER ? DATE PERMIT ISSUED: o DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes -Na Q '\,' �. �i 0 k,. '� o� "� No ................ THE COMMONWEALTH OF MASSACHUSETTS "J BOARD OF HEALTH r. ............................OF......................................I................................................. Appliration for Disposal Vorkg Tonatrurtion Prrutit Application is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal System at: System SlrtIVY !!��.....HY .................................... 7- ........... ............................. .............................................................. Lo Address or Lot No. 97 ..............IX.1�L........... Ante ....... Address 5— .................N .. 0.................... -..b...................................................................................... Installer I/ Address // /-, 1� Type of Building Size Lot__1__,.t................... Sq. feet U Dwelling—No. of Bedrooms............................................Expansion Attic Garbage Grinder ( P4 Other—Type of Building No. of persons...........Y---------------- Showers Cafeteria ( A4 Other fixtures __________________________________ --------------------------------------------- -------------------------------------------------*----------- Design Flow................ S_C� _.___._________._______.___gallons. W ............................gallons per person per day. Total daily flow.......;�ZC�, P4 Septic Tank—Liquid capacitylPqd..gallons Length---------—.- Width__......--.._.r= Diameter--.-__----_—. Depth..: ....... Disposal Trench—No. ........ Width____________________ Total Length..__.__....._......_ Total leaching area....................sq. f t. Seepage Pit No.........I---------- Diameter.._... Depth below inlet......6.1......... Total leaching area...W4....sq. ft. Z Other Distribution box ("') Dosing tank ( ) Percolation Test Results Performed by..J_ 'j.....910� ..................... Date.... ................ ..... .................. I Test Pit No. .___.____minutes perinch Depth of Test Pit----&--------- Depth to ground water.-AOA4��dr, Test Pit No. ...minutesper inch Depth of Test Pit----/Z......... Depth to ground waten. ------- ---------- --- Y.........................................k........................... ........ soo'e...... ........................................ . ........................................ ........................./. 0 Description of Soil..AL_ 2- 6-Z ..................................................e I Z"^ero ---------------*---------------------- --------------- ........................................................ -----------------------............................................................................................................................................................................ U Nature of Repairs or Alterations—Answer when applicable-------------------------------------------------------------------------------------------------- ..................................................................................................................................................................................................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of'TTL7:, 5 of the State Sanitary Code— The undersigned further agrees not to place the system in ,L- operation until a Certificate of Compliance has been issued by the bra-d of iealth. L--- Signed C ✓_-7 I�K a ......... ......9/!L.l: ;Ai S...... Da e Application Approved By.............................. ------ .............. --------- .....----- Application Disapproved for the following reasons:................................................................................................................ ........................................................................................................................................................................................................ Date PermitNo......................................................... Issued....................................................... Date IV O... m + �•" FEE........ . ............ THIJ COMMONWEALTH OF MASSACHUSETTS - BOARD OF HEALTH �. _.... - OF....................................... a Application is hereby made for. a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at t ........................................................ --•----•-•- .,.........•..... --•••---------•-••••----•--• -•- -•• ••--....•-----.. -------•-••---------•-- Location Address or Lot No. t N: fit'f ` r' ¢ }at° rY` =—r-r. =�---^........................... er Address W....� .. _...........!4jfx}jam" .... a ` ...................................... ............................................................... _1.x +„ Installer Address d Type of"Building Size Lot__ ._.. �"....Sq. feet U ______________________________Ex Expansion Attic Garbage Grinder Dwelling—No. of Bedrooms._.__._ p ( ) g ( ) 04 Other—Type of Building 9 No. of persons___._._._�--------------- Showers ( ) — Cafeteria ( ) a Other fixtures --------------------•-----••-- ----- 4�, d'a W Design FFlow___________ J�a _________________________________gallons per person per day. Total daily flow....... . _..............................gallons. G; Septic Tank—Liquid capac•ty_+(':�.-__gallons Length---------_"':_. Width........ Diameter----------m"~:Depth___ ....... Disposal Trench—No._.N ........ Width.................... Total Length_____.__..A__.____ Total leaching area....................sq. ft. Seepage Pit No._______._I--------- Diameter----__1�`'___._._. Depth below inlet...._6t_......... Total leaching area.__:: 4_.__sq. ft. Other Distribution box (`'') Dosing tank ( ) _ a. Percolation Test Resin Performed by- mil-� "E __� `.:� ='_ ______________________ Date_._ ` '_�� a Test Pit No. 1___ __ ___minutes per inch Depth of Test Pit...../I......... Depth to ground water _t` d__...... Test Pit No. 2__ `:^...minutes per inch Depth of Test Pit....1 .......... Depth to ground a J a ------------------ O '�- +r� •. �.. Description of Soil •••••--••••••••--..--...-.------•. •-• • ••• -•-.._....••••- V '- 1 W -•------------------------------------------------•------------------•---------------------•-•----•---••----------------------..-.-----•...--•---•-•-----•-•-----•---•-•----••-••=•-------••----•-••••- UNature of Repairs or Alterations—Answer when applicable- Agreement: ' The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of:i. y g g p y 5 of the State Sanitary Code— The undersign furtl era rees not to lace the system in operation until a Certificate of Compliance has been issued b}i the bi d of iealth. Signed4 C..7-------�-'6.................... �[~CC�•� -- -ff.......... ��..E��` / Dafe Application Approved By.................... ......6-elc_"�----------------- -------- ! ---....--- ate Application Disapproved for the following reasons-------------------------------------------------------------------------------------------------------=---•-•--- Date PermitNo......................................................... Issued................................................=-...... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ........................`'" ...........OF... r7�1 ^",..:........................._.........._............_... TrtgfirFa#r of Tout pli atta THIS IS TO CERTIFY, That t ndvidual ewa isposal Sy em constructed ( ) or Repaired ( ) by-------------•-•-••-----..._�....--------•---•--•--..._......----............,_.....----- - -- ....... ............----•---..._....._......................--•- --.........._ , � I Ilr at........ /.----- /a -------- has been installed in accordance with the provisions of TITLr: j of The State Sanitary Code as described in the L application for Disposal Works Construction Permit No.B______/_•_�0�..........._..... dated----...........___;_ __.._..1;., ._..____.____ THE ISSUANCE OF'THIS CERTIFICATE SHALL NOT BE-CONSTRUED AS A GUARANTEE THAT TIME SYSTEM WILL FUNCTION SATISFACTORY. DATE........................•-------....�_� / PAL = Inspector------ `' �r=---•---------•----------...•••---•--•••------..........-- k.- . . THE COMMONWEALTH OF MASS BOARD>. BOARD OF HEALTH '#�"" ' ql. ...... ...... OF........................................ NO......................... FEE`___ .............. Bilipos al luja�ro TaimArttrt' Permissio ereby granted ----------------------- .............� ---..... ---- ---------------------------------------------------- to Constr c or.Repair ( �_an jlndividua Sewage Disposal stem atNo......----- /F�......•--------------•--�"� �........I-------- ........................................................................ Stree as shown on the application.for Disposal `Forks Construction Permit No..................... Dated........................................... =� �,r - ---- DATE_ _ /4`f,2... oard of Health FORM 1255 HOBBS & WARREN, INC., PUBLISHERS .. tl . _ - •. JIB v ;-p t i ( i .-7 0 r PST! 1 I— CaAL- 9 s,3 t o 8 q 22t , JEST03LEfall o .:a r ?i i B 1�.1F1 I l xP RIO 98.5 _ .1 9 %cT d2' • SH OF 61q / "—AAA o JO 0 :�+ o� ALBERT, t:.r,=> E- a 28874 MDR3 �, vv i [� i F 1 i Q/8T��Q` A No.10951�O NO SUR� � goFF`G/STEP FSS/0NAL LEGEND EXISTING SPOT ELEVATION OxO CERTIFIED PLOT PLAN . EXISTING CCiNTOUR --- p --- Ga7 ,/va sL �� FINISHED SPOT ELEVATION Q. ILI yF,i FINISHED CONTOUR — 0 - IN APPROVED 3 ®OARD : OF HEALTH Pay r:-tos, DATE AGENT SCALE= /"= 3v " DATE t LDREDGE ENGINEERING CQ /N ��H.�kAN�A'5 CLIENT 1 CERTIFY THAT THE PROPOSED y�,411 lL EGISTERE REGIST"E4 JOB NO. 8� BUILDING SHOWN ON THIS PLAN CIVIL LAND CONFORMS TO THE ZONING LAWS' , ENGINEER URV DR.BY4-,�-�,-'M ' OF BARNSTAB El ,+1rI�lASS. 712 MAIN STREET-, CH. BYE "� HYANNIS*. MASS , .; SHEET— OF DATE REG. LAND SURVEYOR ,f N0TE /F E/TNER NE.SEPT/C TANK OR /7GEACLvllvG` P/T ARE MORE Tf/.q:`/ /2' SA--Lo W IC3 FT /rlIN. S.eAOF� 24 "D/AMETEK CONCRETE COliER SHALL BF BROUGHT To GAgA o.E.�.-;,✓ EXT,?A CO/VCRCTE ✓ `0 PVC P/PE t�+E4Vy CA57- /AO%Y' CO(/ER S//.4GL 3E USED MIN. P/TCN � . EL 98.S COVERS �B•PER IF"//V DR/ViF kVA Y ..., a . . . CL EAN SA;V O 4~CAST u — 2 LAYER �= tr MIN.P/TCN OAI.. • . . . r r o o SEPTIC TANK _ DI sT• o , • . r r , ; WA SHEO S7LNE j BOX ° v. o • �. $ ► • o • • � ' .�o �' ' - � i e � r •EFFECT/VC �: � � � 3�4'- � �2" i • • D�T/•1 • • ° v o 1VAS.51E0 STONE T/7 C•4��.�c<�'•y. .. ►a. ► • • • .o • . r p�p PiPEC45 T,SEFpAGE INVB/qT &L RVAT/oNS t 8fl x Z S 17170 D ► r ► • • . • . r ' e o P/7 OR EQUi v. INVERT AT 441/LD/NG 95:5: FT.. . q GA L INLET Ti4NK 94.5- FT, T.F O/AM. C(SEE TABULATION • OC/T T LE SEOT/C T K.AN 94:3 - 1 INLET D/ST/q/8!/T/ON BOX 9 3.3 FT. SECT/ON 4 F GROUND W,47fR TABL E O/ITLETD/STR/B[/T/ON BOX INLET LEACH/Na PIT 92.5 FT SEWAGE O/SPOSA L SYSTLC/►f LEACHING P/T 'TABULATlDN DES/GM CR/TER/A SCALE :. DIMENSION A O/.•f.E/VS NIlMDER OF 6EOROOMS 2 D/MENS/ON C 4 FT ^/ G'40aA4G'r0/SP0."1. UNIT ,�JovE SOIL. LOG .TOTAL EJT//►?ATED FLOW 224' GAL.10.4Y SOIL TEST / SOIL TEST2 SOIL TEST itlUMAZA OF LEACHING PITS f'E[EK. g-',S / -ELFY, `� 3 �Z —_3 DA T..E' OR SOIL, TES T SIDE LEACHING PER R/T S �T �j r U — ` RESULS E T PV1'NESSD BY ARE �i��oiao BOTTOM LFr4CN/NG PER PIT 7� Lo i"1 d'c' PCR LCS S 2� b LOs?--rvl a- -• CQ�AT/ON MATE�/ M/N�/I NChf i TOTAL LEACH/NG AREA SQ. FT. ��,/) FfftCOLAT/ON RA7-6q RESERVE 4EACH//V6 AREA tab SQ. F,T. �� 2 ^jZ '118OF n / O F. M i �N . .Mgs r 5 nl� M p P ' 9 y•, e r i 2 ,ti .So`f G , ul " -4 o f h M'ORSE l ci 4 C �No 10951 O Q F �.� ��• ELOREDGE ENGINEER/NG CO,/NG. {Et N lie �Q` GISTS�� NA� � CL_ 6 7. 5 �L �/. 3 71Z Mil/N ST. , f/Y'QA1NiS, Nlgss. i L, (�. ND GROUN0.YVATL`R E/VCOU/VTERSO CL/ENT:V•4 AX,aroGr DFITE `+� !'Z I 82 Q GROUNL7 I.vATE�P AT EL EL! _ JOB NO: 8/13.7 SHEET Z-O 2- Town of Barnstable Health Inspector OFtHE Tp� Office Hours ti Regulatory Services 8:00-9:30 yP �� Thomas F.Geiler,Director 1:00—2:00 * STBLE, • Only B"NA Ass. g i6gq. Public Health Division qj ♦0 ArFO ,�a Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 AMNESTY PROGRAM APPLICANT QUESTIONNAIRE 1. General Information: Address: _ A MapParcel -LO,5 Name: e 0 C4 a, �71r 'qo n Phone: 4 -7 -7 r—o 1 -7 7 Work- -7-71-77Ua 2. How many bedrooms exist on your property now? 2a. Please include a copy of your floor plans for the entire property. �/� 3. Is the dwelling connected to public sewer? YES or NO If the dwelling is connected to public sewer, skip questions 4-9 below. 4. Location of dwelling is tv or OUTSIDE a Zone of Contribution to public . supply wells? 5. Is the dwelling connected to an ONSITE WELL or to (:—P1'UB=LICWATTER? 6. Is a disposal works construction permit on file? YES or NO n 6a.If yes, how many bedrooms were approved according to this permit? N /1 Bedrooms. 7. Were any building permits obtained for construction of additional bedrooms? YES or NO 8. Is there an engineered septic system plan on file at the Health Division? YES or 9. Has the septic system en inspected by a DEP certified inspector within the last two years? YES or (�V l � i / �WlT. ��/��/,�c4a FOR OFFICE USE ONLY TO BE SIGNED BY A HEALTH INSPECTOR/AGENT ONLY The Public Health Division has no objection to 3 bedrooms at this property. Signed: -J /�). A�)LQSDate: 1 z -2 D a Inspecto4(( rint): ,,. Q;lhealth/wpfi leslamnestyapp Town of Barnstable Health Inspector IME 1p� Office Hours Regulatory Services 8:00-9:30 M Thomas F.Geiler,Director 1:00-2:00 BARNSTABLE, • Only 9� 69. Public Health Division ArFOMA'�a Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 AMNESTY PROGRAM APPLICANT QUESTIONNAIRE 1. General Information: Address: &444Map Parcel c U, Name: G e 0 r4 e, r' q Phone: I -7 -7 r—a 7 work_ -7-71 770 a 2. How many bedrooms exist on your property now? 2a. Please include a copy of your floor plans for the entire property. .le 3. Is the dwelling connected to public sewer? YES or NO If the dwelling is connected to public sewer, skip questions 4-9 below. 4. Location of dwelling is NSIDE or OUTSIDE a Zone of Contribution to public- supply wells? 5. Is the dwelling connected to an ONSITE WELL or to PU=PWATER? 6. Is a disposal works construction permit on file? YES or NO 6a.If yes,how many bedrooms were approved according to this permit? 0 /1 Bedrooms. 7. Were any building permits obtained for construction of additional bedrooms? YES or NO 8. Is there an engineered septic system plan on file at the Health Division? YES or 9. Has the septic system n inspected by a DEP certified inspector within the last two years? YES or NO / --------------------------------________________________________(____________________-_______________________________ FOR OFFICE USE ONLY TO BE SIGNED BY A HEALTH INSPECTOR/AGENT ONLY The Public Health Division has no objection to _ bedrooms at this property. Signed: Date: J-1 L,):2 Inspector rint): ,, Q;/health/wpfiles/amnestyapp a� ec I !1 p �✓ 1J e� c� cy Ilk I oe lo O i -S � � GS s �S C 0 v I Cy` �'` ! H d't r 0 a 1 C � O a 4 a � c�X t . � rr, M COMMONWEALTH OF MASSACHUSETTS fr. . EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION d . Y elf , TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 67 SHADY LANE HYANNIS,MA 02601 Owner's Name: WAYNE ZERVIS Owner's Address: BOX 674'CENTERVILLE MA.02632 ' Date of Inspection: 11/16/005 t�. Name of Inspector:(please print) - 'JOHN GRACI Company Name: SbTIC INSPECTIONS , Mailing Address: W P.6 BOX 2119 TEATICKET,MA.02536 Telephone Number: 508-564-6813 FAX 508-564-7270 f �Ivu ,,. Nov CERTIFICATION STATEMENT r 2000 I I certify that I have personally inspected the sewage disposal system at this address and that the"mformaton=reported below is true,accurate and complete as of the time.-of the inspection.The inspection was performed based4on my trammg and experience in the proper function and maintenance of on site sewage disposal systems.I am a DEP,approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: X Passes _ Conditional Passes _ Needs Fu er Evaluation by the Local Approving Authority Fails Inspector's Signature: Date: 11/16/00 The system inspector shall subiji a copy`of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection;If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall ubmit the report to the appropriate regional office of the DEP.The original should be '4 sent to the system owner and copies's_eht to the buyer,if applicable,and the approving authority. Notes and Comments THE SYSTEM PASSES TITLE V INPECTION.RECOMMEND PUMPING THE SYSTEM NOW AND EVERY ONE ' YEAR TO PROLONG THE SYSTEMS'USEFULL LIFE. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use., h . Title 5 Tncnrntinn Fnrm 6/1 VIM) 1 Page 2 of I I :k j. Y' P OFFICIAL INSPECTION FORM—NOT FORVOLUNTARY ASSESSMENTS 191 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A , 9,a 7 ; CERTIFICATION(continued) p Property Address: 67 SHADY LANE HYANNIS,MA 02601 �. s Owner: WAYNE ZERVIS N.1 Date of Inspection: 11/16/00 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: X I have not found any information which-indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. IS Comments: THE SYSTEM PASSES TITLE V INPECTION.RECOMMEND PUMPING THE SYSTEM NOW AND EVERYd ONE YEAR TO PROLONG THE SYSTEM S USEFULL LIFE. B. System Conditionally Passes: � _ One or mores stem coin onents as described in the"Conditional Pass"section need to be replaced or repaired.The.system,stem, a Y P P P Y 1,�� " , upon completion of the replacementoc repair,as approved by the Board of Health,will pass. �? Answer yes,no or not determined(Y,NND)in the for the following statements. If"not determined"please explain. n/a The septic tank is metal and over 26 years old*or the septic tank(whether metal or not)is structurally unsound,exhibitsi c substantial infiltration or exfiltration or tank failure is imminent. Systemmill pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating- that the tank is less than 20 years old is available. t �r* ND explain:n/a �i F n/a Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or unevenadistribution box.System will pass inspection if(with approval of Board of � +" I a5as y as Health _ broken pipe(s)are replaced _ obstruction is removed _ distribution box is leveled or replaced ND explain:n/a 1, n/a The system required um in g{more'than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the board of Health): _broken.pipe(s)are replaced _obstruction is removed 3 ND explain:n/a 1t t f I<S f 7 e� Page 3 of 11 ! a yy Y t I, C�j OFFICIAL INSPECTION FORM-NOT FOR;VOLUNTARY ASSESSMENTS Ip �J 0, t� SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 67 SHADY LANE HYANNIS,MA 02601 7 � w Owner: WAYNE ZERVIS r E Date of Inspection: 11/16/00 C. Further Evaluation is Required by the Board of Health: Conditions exist which require fiirther-•evaluation by the Board of Health in order to determine if the system is failing to t protect public health,safety or the;;environinent. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system not functioning in a mannerjw;hich will protect public health;safety and the environment: x, `4 �41 , < M" a i �„µ• _ Cesspool or privy is within 50'feet of a surface water �a I _ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh Res < 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the, ublic health,safety and environment: Y h P ,1? Y The system has a septic tank and soil absorption system(SAS)and theSAS is within 100 feet of a surface water. M' supply or tributary to a surface water supply. _ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. _ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. y _ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private watery'}, supply well".Method usedlio determine distance n/a "This system passes if the Wh'water analysis,performed at a DEP certified laboratory,for coliform bacteria and , -," �r volatile organic compounds iAcates that the well is free from pollution from that facility and the presence of ammonia i fil nitrogen and nitrate nitrogen is'equal to or less than 5 ppm,provided.that no other failure criteria are triggered.A copy j4 � f of the analysis must be attached to this form. 3 ik 1 , 3. Other: ,, ` n/a ,. 5""2 tt 9 y, ! Page 4 of 11 F EM OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM k L ' i#*r PART A CERTIFICATION(continued) , Property Address: 67 SHADY LANE HYANNIS,MA 02601 f s Owner: WAYNE ZERVIS Date of Inspection: 11/16/00 r � r% n D. System Failure Criteria applicable to all systems: You mnst indicate"yes"or"no"to each of the following for all inspections: Yes No '. . X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool , t V. ., X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ,&A X Static liquid level in the distribution box above outlet invert dt e'to an overloaded or clogged SAS or cesspool X Liquid depth in cesspool is less than 6'below invert or available volume is less than ''/z day flow _ X Required pumping more than 4 times in the of times the last year NOT due to clogged or obstructed pipe(s). � PUMP n&. X Any portion of the SAS,cesspool or privy is below high groundwater elevation. i X Any portion of cesspooFior privy is within 100 feet of a surface water supply or tributary to a surface water supply. D } X Any portion of a cesspoohor pri"is within a Zone 1 of a public well. X Any portion of a cesspool or privy is within 50 feet of a private water supply well. X Any portion of a cesspool'or privy is less than 100 feet but greater than 50 feet from a private water supply well with � � t no acceptable water quality.analysis. [This system passes ifthe well water analysis,performed at a DEP certified laboratory,foricbliform bacteria and volatile,organic,compounds indicates that the well is free ` li from pollution from that,facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or 4 h '7; less than 5 m provided that no other failure criteria are triggered.A co of the analysis must be PP �P gg PY Y attached to this form.] _ (Yes/No)The system fails.I have determined that one or more X.the above failure criteria exist as described m 310 CMR 15.303,therefore the system fails.The system owner should contact,tlie Board of Health to determine what will be necessary to correct the failure. i ' sny E. Large Systems: `#b' P ` + To be considered a large system the system must serve a facility with Fa design flow of 10,000 gpd to 15,000 gpd. t1 You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) �� yes no _ X the system is within 400 feet of a surface drinking water supply, , X the system is within 200ryfeet of`a.tributary to a surface drinking water supply X the system is located in a`nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped4 Zone II of a public water supply well - (, If you have answered"yes"to.any question in Section E the system is considered a significant threat,or answered "yes"in Section D above the large systiin has failed.The owner or operator,of any large system considered a significant threat 4' under Section E or failed under Section D shall upgrade the system in accordance with 310 IX CMR 15.304.The system owner : {� µF. r is h. w ti should contact the appropriate regional office of the Department. , 4 4 1 l ti N 2g35 Pi , ti d Page 5 of 11 11 ,• i. s, OFFICIAL INSPECTION FORM—NOT FORNOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM aid, k�I� PART B �,4 ��Y. CHECKLIST:' Property Address: 67 SHADY LANE HYANNIS,MA 02601 Owner: WAYNE ZERVIS Date of Inspection: 11/16/00 �:' Check if the following have been done.You must indicate"yes"or"no as to each of the following: Yes No X _ Pumping information was provided by the owner,occupant,or Board of Health a X Were any of the system components pumped out in the previous two weeks? X _ Has the system received normal flows in the previous two week period? ajyt rj+ X Have large volumes of water.been introduced to the system recently or as part of this inspection? X _ Were as built plans of the system obtained and examined?(If they were not available note as N/A) X _ Was the facility or dwelling inspected for signs of sewage back up? q. X _ Was the site inspected for signs of break out? X _ Were all system components,excluding the SAS,located on site? X _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum . X _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance ,,`l�rs of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: ff Yes no X _ Existing information.For example,a plan at the Board of Health. X _ Determined in the field(if`any of the failure criteria related to Part C is at issue approximation of distance is k141 unacceptable)[310 CMR 15.302(3)(b)],, •�sl;� r 1 I 4n1E, .F J%,�.iJ✓}°fir$. t,13�xi1 ..f�� 'JA icy;A Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ' PART C` 'E SYSTEM INFORMATION Property Address: 67 SHADY LANE HYANNIS,MA 02601 Owner: WAYNE ZERVIS ; Date of Inspection: 11/16/00 i.iuS FLOW CONDITIONS RESIDENTIAL s ' Number of bedrooms(design):3� Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 for example: 110 d x#of bedrooms):330 ( P gP ) „ Number of current residents:2 Does residence have a garbage grinder(y`'s or no):NO Is laundry on a separate sewage system(yes or no): NO [if yes separate inspection required] ¢f O Laundry system inspected(yes or no):N ; Seasonal use:(yes or no): NO ( y g (gP )): Water meter readings,if available last 2 ears usage d n/a Sump pump(yes or no):NO 4t'r �Y Last date of occupancy: n/a 4 : 1 COMMERCIALANDUSTRIAL ` } Type of establishment: n/a Design flow(based on 310 CMR 15.203): n/agpd t:„+ Basis of design flow(seats/persons/sgft,etc. : n/a Grease trap present(yes or no): NO Industrial waste holding tank present(yes or no): NO s Non-sanitary waste discharged to the Title'5 system(yes or no):NO r;, Water meter readings, if available:n/a Last date of occupancy/use: n/a , OTHER(describe): n/a ` GENERAL INFORMATION Pumping Records Source of information: n/a ,r i' Wass stem pumped as art of the inspection es or no :NO Y P P P P (Y ) 9� If yes,volume pumped: n/agallons--How'was quantity pumped determined?n/a ` Reason for pumping: n/a �•' fir:,$,. ;.: V. TYPE OF SYSTEM X Septic tank,distribution box,soil absorption system _Single cesspool 'f 1 : Overflow cesspool `r _Privy _Shared system(yes or no)(if yes,attach previous inspection records,if any) _Innovative/Alternative technology.Attach a co of the current operation and maintenance contract to be obtained from PY p ( system owner) » �` _Tight tank Attach a copy of the DEP approval ' Other(describe): n/a ,`F Approximate age of all components;'date installed(if known)and source of information: 1981 Were sewage odors detected when arriving at the site(yes or no):NO t.�q xik tt lw {i 4 ,5 Page 7 of 11 a S. d+, t, OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) gt' p Property Address: 67 SHADY LANE.HYANNIS,MA 02601jt Owner: WAYNE ZERVIS ' + Date of Inspection: 11/16/00 ;iM: BUILDING SEWER(locate on site plan) Depth below grade:30" Materials of construction:_cast iron X40 PVC_other(explain): n/a ¢' Distance from private water supply well or suction line:n/a r Comments(on condition of joints,venting,evidence of leakage,etc.): TOWN WATER SEPTIC TANK:X(locate on site plan) Depth below grade:24" 1 k� # 4' Material of construction:Xconcrete metal_fiberglass_polyethylene other(explain)n/a .� If tank is metal list age:n/a Is age confirmed by a Certificate of Com fiance es or no): NO attach a copy of certificate Dimensions: 1000G L 81 6 H 51 7 Wq4 10 Sludge depth:3" ;r, F, Distance from top of sludge to bottom of outlet tee or baffle:31" ;y Scum thickness:4" ''' > Distance from top of scum to top of outlet tee or baffle:6" t 1 Distance from bottom of scum to bottomOfloutlet tee or baffle: n/a How were dimensions determined:MEASURED Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related t 'Ai41 to outlet invert,evidence of leakage,etc.): THE SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND.RECOMMEND PUMPING NOW AND EVERY ONE YEAR TO PROLONG THE SYSTEM'S USEFULL LIFE. ct1' ri GREASE TRAP:_(locate on site plan) 4. Depth below grade:n/a ' Material of construction:_concrete_metal_fiberglass_polyethylene other(explain): n/a rr,•; ;.,..:74. Dimensions: n/a Scum thickness: n/a Distance from top of scum to top of outlet tee or baffle:n/a Distance from bottom of scum to bottom of outlet tee or baffle: n/a Date of last pumping: n/a Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc): n/a 1i N,N Page 8 of 11 a Y A �r `� " OFFICIAL INSPECTION FORM—NOT FOR"V,OLUNTAR S SESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C I''.' ', SYSTEM INFORMATION(continued) , Property Address: 67 SHADY LANE HYANNIS,MA 02601 Owner: WAYNE ZERVIS Y td Date of Inspection: 11/16/00 <; l TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) i n4 Depth below grade: n/a C Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a Dimensions: n/a Capacity: n/a gallons Design Flow: n/a gallons/day 4i Alarm present(yes or no): N/A '4� Alarm level:N/A Alarm in working order(yes or no):NO 3 ' Date of last pumping: n/a 1 A Comments(condition of alarm and float switches,etc.): 7, � n/a , ,51. DISTRIBUTION BOX:_(if present must be opened)(locate on site plan) G Depth of liquid level above outlet invert: n/a Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into p ,� or out of box,etc. : 5' PUMP CHAMBER:_(locate on site plan) � ! Pumps in working order(yes or no):� O Alarms in working order(yes or no):NO t k; °tsx � Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.):10 ify� r n/e �{r r d fII a•r�!�3 i L( f }} �0-sI{ R� NZ z ',` Page 9 of 11 1: 1,, OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C I SYSTEM INFORMATION(continued) . Property Address: 67 SHADY LANE HYANNIS,MA 02601 { Owner: WAYNE ZERVIS aj Date of Inspection: 11/16/00 SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,excavation not required) If SAS not located explain why: n/a 1-. }dd 4 Type 1000 GAL 6'X 6' leaching pits,.number: 1 ,;z n/a leaching chambers, number n/a F n/a leaching galleries, number n/a t n/a leaching trenches, number, length: n/a n/a leaching fields, number: n/a as n/a overflow cesspool, number. n/a n/a ' ' : •innovative/alternative system #" Type/name of technology: n/a 4 Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.): fl ` THE LEACH PIT IS STRUCTURALLY SOUND AND APPEARS TO,BE FUNCTIONING PROPERLY.THE PIT ' HAD 6"OF LEACHING LEFT AT THE TIME OF THE INSPECTION.SYSTEM SHOWS NO SIGNS OF t FAILURE. CESSPOOLS: (cesspool must be pumped'as part of inspection)(locate on site plan) Number and configuration: n/a Depth—top of liquid to inlet invert: n/a Depth of solids layer: n/a Depth of scum layer:n/a Dimensions of cesspool: n/a Materials of construction:n/a Indication of groundwater inflow(yes or no NO Comments(note condition of soil,signs of'hydraulic failure,level of ponding,condition of vegetation,etc.): " . s n/a i u PRIVY: (locate on site plan) ' } 4 r: G�i fr�ti Materials of construction:n/a fy . Dimensions: n/a Depth of solids: n/a ; Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): n/aso It, ,t t X'T li!tzil.{ t Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM 't=' PART C SYSTEM INFORMATION(continued) Property Address: 67 SHADY LANE HYANNIS,MA 02601 Owner: WAYNE ZERVIS ;{'4 Date of Inspection: 11/16/00 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. :,; Locate all wells within 100 feet.Locate where public water supply enters the building. ;pphppp,eX,: of ent s �,. t • J� 3` liC7 • s P�, �;' } it tits(t sfi4 k�r 2n� .q, ✓•' � tg in Page 11 of 11 d i OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C '�SYSTEM INFORMATION(continued) {[ Property Address: 67 SHADY LANE HYANNIS,MA 02601 Owner: WAYNE ZERVIS hr , Date of Inspection: 11/16/00 SITE EXAM _Slope _Surface water _Check cellar _Shallow wells Estimated depth to ground water 12+feet 1j Please indicate(check)all methods used to determine the high ground water elevation: NO Obtained from system design plans on record-If checked,date of design plan reviewed: n/a NO Observed site(abutting property/observation hole within 150 feet of SAS) NO Checked with local Board of Health-explain: n/a NO Checked with local ex6vato'rs•installers-(attach documentation) YES Accessed USGS database explain: n/a +:roll t You must describe how you established,the.high ground water elevation: +FE >.„ s USGS MAPS AND CHARTS- 12ET a t jrr i n y "a, .r:l .;yk": 11;-A i 2 +f Page I of- CAPE COD BUDDING Cape.-Cod Building Inspection Services INSPEC W 1230 Newtown Road Cotuit, MA 02635 (508) 420-0260 4 LETTER OF LEAD ABATEMENT COMPLIANCE DATE: l0 - R 93. DEAR T 4.0 This letter is to certify that I inspected your property located at apartment no - and relevant common areas, in the city or town of.' for lead abatement compliance on 1 5' 5' and on that date those surfaces cited in the initial inspection report of i : were found to be in compliance with Massachusetts General Laws, Chapter 111, Section 197, and 105 CMR 460.000 Regulations for Lead Poisoning Pervention and Control. Massachusetts law does not require the abatement of all residential lead paint. The residen tial premises 'or dwelling unit and relevant common areas shall remain in compliance only as long as there continues to be NO peeling, chipping or flaking lead paint or.other accessible leaded materials, and as long as covering forming an effective barrier over such paint or other leaded materials remains in place*. See the other pages of this letter for location(s) of surfaces which were covered as an abatement method to achieve compliance, if applicable. ........... ..._ ........._............. _ * Notes: ... Sincerely, Not Valid � Minc r u,4Without ** As of above date of regulation it will be the responsibility Inspector Seal of the owner to be aware of any future changes in the law. Report# IG`� Registration No. INSPECTION AND ABATEMENT HISTORY e ay Name and Regis ation Number of Inspector Who Preformed Initial Inspection Date of Reoccupancy Reinspection Name and Registion Number of Inspector ( if applicable) Who Performed Reoccupancy Reinspection Name(s) and Certification or Licence Number(s) of Department of Labor and Industry Authorized Deleading Contractor(s) Who Performed Abatement: c t_100 �s Fey 4.1 11 ,7A 4M a 'Ilk" ' S �6 4 r, a,UFFI Certificate Of Compliance s w 2 { d d ..r ri'a4 3 i ' 3� .; ISIA . certify that we have inspected the premises identified below and based Pon ouramspection hake not found evidence of Urea Formaldehyde Foam Insulanon�(UFFI)' °•�f ic. x � + �} weer MNi ame t ��,n.� der v i cA e' ' esSL�ocation t�, l.S-- •-- Crty%Town� a...t s State: \A � h a t .1 ,. ro'9�.'x7sa`��`i��d,7'"1;4�A�"}.•y ti+ �y + ( # of�CertificaUon F,,,s$ 7. i� r a s Certified by 77 �^rC kAi $f ��1 fi.�rX� �:f�'��r }��`l 4 `E.° � yr$ ,_ '• .. , j a�i a"^4i}y � yktti W "Agerit�Oft w f% INSPECTOR UFFI PO Box 1347. al njji ' Brewster MA 02631 f 1-800-343-4777 kip A t ( y Ca� S S�tav t ! x i ' t 4 .A 1 }tt"',A A.e t It r• >•' v ' ai dk-z 1 r l - r°+f tk ' �/�•t' R FO� 7JV'"Y 7M�1 h 'yA1 d's?tt.r 4 t lt°�w Revised.9/83' r �,AV t 4 +'�e�FFxti3;yT .e CYraM,+u�,:*37" > k ltr at -�,..� � ...-_ •___...._. .. .... s... -.w.�.._.�......_.�� , y,ab 1s� tAl +• r3,l�M", } 1 }h_. i I!,ir �' re � '!J"C � J Stateinet of Authorization ''Jv rr Jy C1ti {� 18 CI � Owners Name t J a + .•� ��✓,f?ti5'S£"�Mu�Sa b t.. ',.1 ♦W4//`J �.t �vv'ww..•. - -v 3 kemises'Location -} '`€ �a� 4mi•� 't t " `Lem .r x y ?f r•, txb}fK,� {\Y .� State. Zip. 3 tr M t� 1J f{ 6. !' -Ail r��„r # + State: :Zip: hone dumber ,.a��. .Si rt�:•��'4 5<�,7nrx�§�t �C y y A:.. h ebauthonze INSPECTOR UFFI to proceed with the analysis of any,foam �- ,meµ 0. y,...,(�SsfS 4f `^ (nM t Y. -1 Y i_nsulation,samyplertalcett�fromJth6'above premses.y-pe I understand that a written. reportoftsaid analysis'will'be,tssued to me within 21 days of the inpsection. #Q �r�.lR4� � 1,5'ttatit;J to�S rrz 7c+„�rJ�tG} nur w � 4 S z - 4 k' J, 14, 1 w# J rf JJt��,ltss ' Date: Signed ,r+.N ��yt��r' `t�i2.1a,a 7.�3 �h✓ t A. { �`�� <+{,5;� �}��rr;x�i;`7�,��rt T,�.h�.•f r�l...m"ff,�t. _. . .... ... ..... .... � _. ., � c � i��'i�s':� ^�n7�a��tw+r a3t�' uz, �ti} +;.;�•' s :- - ,. . `,.:,• . , a+ IDO�OT+�authorize;I�ISPECTOR UFFI to proceed with analysis of any foam Fus�ulatlon fo�und�ui"the�above premises.` #IIe�,i,�� S4��S p5 C9 � Date: It; i,r.F Fr.{,k t n 'T ''7d.?d' '✓d'•a' w'4''v !{✓fW M }x.;if°v(ex.� N AN.� 1"r ;A, }.ahr y,J�tykra - ' : P1'ease send}a'copy,'ofFthis reportto the third party designated below. n ;. , U t .t.�C+�E��'r - ,f. Date: �t 1 Y�N m W ,.'��y Cf#,,�55t" y'kwa�FoJ7 d�'}35�J ,n f ✓ �,k'� f F+ Name , r �y 4,.} 1 d £`J,.. �`.z�fkAddress `t - .Y tt }City�T,own �.K. xr�r,�nn. d aunt a .a '..$tate: :Zlp. t' .,19 �`f3- t�,�4�°�'{hq�� F n�} thpT � g,�d } - ca ✓ �. i t3' dJ $ '`ktid t Y Jl 4 to + L a-at ' ; t - t r � .� fE^ ,trffi'�'E3� ,. t� INSPECTOR `FF1 y; #. a�� iV4+bj �. gut '; fr y� PO Bax 1347 Breiws`er, MAC 02631, 8�Or a -41 / / LLLs� ✓S�` s ��j;x,.,`'s�. s{�-K��7 � tr£ � a f, 't s �_:.p 4 _ J �5 n' � ,,} .,'T �.�• ��{..rt MLt Y 4r�` e',��fi€tF•r��' J Y n � .'� .-4 ,7,�,, '.,i;`�i�flsr et�+�f'ffi"Nhx',�1"bK1•s,"�k eux t k - _ , +� Y d�'ra•y i A?Nk F lt ,. k,^3C� i! A "!%Kii, irk OR - a �Inspe�ctei�opnReport �� 4 J �SY{7 1 r' 1 r +J rl f[ ° r t�3 r [y 1 PIT A '1�,;,�"�'`�'�� •�� jrr�r,��`��,(�„L�E ,.� + ij� r ` fig. ^d ' 3�. �{ 'i5��,�7�+�3�+t1'��'#p,�.,�i({t�`� ^�r�,,,!x y�" �i•$.- '�s v` ea!tx E Y � '-�M h�, e r z to ?.}' "jf, k°r �iFF e a+ "k n� �.,:5,+ f�(7 1,• =2 1 .�a v t Y 4 N � d , , ':< emisesf��:o atio�' � o'' kr� a +fie gg m tv nwk^," r H "rar• a 4 4 r 1.. r t r `�.h, AzV �,,., z`4F,r�, t c"F'tx ? •t (j�+ W },� p StatV ` ,•'t i a ! " - d' � �"HY A,31y'y�*'i4�z,��i r•t��'�'i'� 5�.5 r�,?.�is¢tt p w x s-r e.*'sx a��rt w 4 -�" r v �'"ti Y xt fi v rra,. .•Y! .� •�• ,.SF FS•me.. (}.A l�3t 14,�M'.4s'�ap �t��;! ,y �y l r w j 4 ty i.. i� .< qe 4�'. .€�.. TMri"�5.t"�,,.�F,r4l °Y��a,C .JS't/= i tT.fTTpt.{Yk f - '�' Ye -f 3• S i y, F+ }.• - 1<�C bt :1 d�Fx•t"IFr � e �� j �A. {eay FIN eIiisp cation few +7 ,, s w A r Fiber Optic Utilized k , ! t y p WWOga{,�r'sI�K� t,(fFx� S n r igPe Y'�1S. P�i}t,i „ y,a..t. Ji ry y (:' ,L ,it 7 ) n 'r a,4 a� s.p �•. 5 .. L; •K� i°r �r'tSs N�'.. Cf • xtG or Su�ey'�k ' a-SV -1%, `•' * , s� 8° '' t „LG y�{4r SE1�`+v'i rr Srs ' t rK••. '.< yax Y ffiN'r Yip JfR'S t,(Y#fE i +4 d t y k t r r, •s y ��`�s'q�� {r�F��r a,,.`i��*� F�?��i� �,Xrr�1f' S,a _ �� ' ' h r� a S j:� ' � , ' fiRt�xj ,! , t" 3 tF ,y�x-yy NNy-tmhm ✓ tt e r r� Y i s jf ,i �,y si S?>;~SPzs ; }" 4 Cl pecubm.-Sites x N} .4 ron Ex e777all `?4sc�� '` 4 Rear Exterior Wall r �t H 4' f�F. +�,�, rti t t .�ya z it a 'd �st,"rt. Iyy4AAp,tzi ,.# gagh terior W'tallg4 �ati`t rZ 1°L.eft Exterior Wall o)4- C i fi 9� EN1 + ;'tn,"Jk's +�a� Cellar/Crawl Space` ,„! y ( t Y. `` 3+>rzBl { "{ti;,Yi t4t ,�y�ry . ^v��.r YS�'?h�3' ''y�m'`S�i.aq'f �dt�,;��+}, �-- s e r•. �[ i �' fi past �t nalTns ec �� >f ut � a $ ""ju:t x• 8 miance fot l '} Y r f- Sri s y,,Mr iSR t 4i sf ,r r C x� t 4 `�4�-1z f .,s..:..3.k�n.q�t.,`� •'� "' � i;f/!v+..dvYi1",Ga ,,' tT:Z r ,�v�+ tl. 4.'4g• .f A h x A�� 1 :I � r�i t 451 !• t�l 1J f 1, ',`'7 >t � f 1 R 3 $ yt �'� � tr* � fb fitr "�. ^• + '+ r i q Y d t 4g a' ,� 1v•" t,. [4'krpYu ktr {.Ig rt ,�,,= r r! _ ��' xX x :' Y � `�;��.� c;.}.,t[t4j�t,.n$, ,�y�I tr�f'*. i +r 7.of>� 'A �-; +� `• " d '" '3 W. =yp1 v. ,:F.'fA' W.t It 3S tx4" dad a t A yr fy■' �[y�'g+�/�N''!�,■/'�� .,��[ �..sp 2, a F1 ,i'� z+a a a..� -s� '•y, }' ..utv�Y( �`tktf �Yr�'r't jae�3,tVF 1 "i'�ij�l✓iiiA wO�o� u }f fv r:, S r s h:'4 ,,1 (k r; f:5,� � `ru ,%�F �k� vp"J tY,y...? C.. �ta t., "��z�' i�x a#�rr3f tpr'i�•'t 4 �.` + ' zx i � �i 4Y i4 N K4 ¢A 4d w'$rewster"MA 0263.1 1 ,. yz,e "� � �F .•}t4� `Q` '��'R y;�`'��i�"''}5� a'r �'� '� x i fl; i'e � ! ><•'x. t ! �a It R �� `� r � '�'��h '�' a s` •�;� , r`ti x e., ,z au,rlj ,.e� `r i ,� yYw � � fib, .y;` -� "F' �`�' k 1 n,,a• 4„ay d f r ti 9.a ..? . 4 x , Y- -r s>� 2� � '_�"�� ^+j�r3'a� > ; � e ^f ;� 1 t t � S r r f 1<`,E*`�• Y'Rr +''� r• r .+rt .,..y .7 d `� # y,°°'x, � 1 i c w :_! M f,.. .. �r. •Sr t "�' ya r `i r 3tt n A y,5nd ql�q t+ti f�✓ T r t y Y,r-. p� .. - +, d, - i 4 t f jf r+-�� 5 r d3.''`jY�'��t sz t i� tyiht �!+ s ,y rFj _:°.rt�°°, •� _ ' * �,. ,ct� ��°r r��'�"F�� r ✓ L'�t 14.t=t $� �� t r' a 4J S ! c ! 7l@,aJiy+5r d t+5 Y ">r - anspction°Report Con t. rIr fie• ay'�6 t� S 3j, ` +•u}<,,.��``x+ r t 'ir{ I 7�� 1`)O - aa M. are,�Ye}p I `� 9� w l EtT' "Jar F MAY 1 �l +. 'iN;ws� fS ' a sample taken`forrt,aanalysis x 3��211#=� a °IS kA 4S �t+1'idMIKkr�• onto(2),di&customerjefuservto 1 '` •�' f '�" Px °7;r" g�'"��"i 4Sfq, r s�' ..tit S*N�I T t allows sample forTanalysis? •� s.r +�``�,C -`�� r °tit itrvk✓d'4 ors e". ier+r t d y.,tv .+ :•t, i r i t g [�i �, '�1'+ N?iwp.r�j `r;*;y�+tr'� b}t1*r�if✓q yam.:� � s�y�v�{y t t. r 4 �!� ,, S Number „°f�t �s"Ms dT 54r ltrfa ria�r'�✓�i i a t : c ? - dy .1 Vic'`3+ni'i•(a' r t�'�.-,yr .>u`t t# o-- •( ., t r i - "• z.., + }' v'-_,��vt y�r t€ `v.�.ryf#taF�f bz��,� ga�-Y�wa.�,� r a ; c •I tI 4µiF d �•qpy'y��{{Lf�.',C� Y IR A � y}{ j S t 7 . f �•* ! ✓T.'!9S' h F'p } Zh:��91 0 4'i�� a..f�a 7 '�, k - '• $ .. { tr ,R. ++�{� k y c�` ✓i}1, t4<ri+ t,j t +{3 r v - } t. "q- IR ! '•ir:`I E :,e ' tea t �ha�v�eu�nidfoam'u s5ulat�onat theabove premisestand at this time cannot determine " <".Y r"`EE +i $"-^.I i"'+?::" .. hyuj.'�3(.'t'`�.ja' a+l3�t. a'C;f�f.xayk �.wt ,:,1. ^.Yd ':•;- a <. w. } .:�. R. ° x-?ice !r'; t U'Eea Formalde-hyde''Fgam'Insulation(UFFI) is present. As this date:' k ,• ; +C't,`fY' r,3 ?x Jv a"y '�}7y t��,^rk�J'r+.. A}.£�k}t�'�il}y tY;,47+ t e �Litt I �' i 4 y x t 57 j ��iaIiahave4/;have!not,obtauied a sample for analysis: T" - aP�, .'�i4ei�n�.g�3`�j. l`. +�,�•rAAx».,x'`r�y�� n�t3 try RBI! r ! f •+ ��.: v, a d•z+ ;:} ,r�,.a .• <' } ' ��•� >�-�� } #�Lti`""''!txv -�,h13 at�.�hh�� au� 'tI 1 t .^ F '� ,; � ' +;t Sf ;• w' .,� Ins,pe�tor�s�Signature,r° w . , .Date - <y;.r. ,g�,',�, ye Yr ,g Alta a+.y, i r �, R� -•+ e - .',t ,, Mn ,.,,, ,�§ "��w »QW y}'�i�f ik,3,!a}m�l tl 1i ! t 71 ,4v yk' d 'r', r,�..xT � •x,a i.J' 4 a f .S 1 +€ � 9,h`YL•�:,rr �•w t#e F+`F7:v}fi Nr !it .., � 3_ have inspected4,the;above premises and based upon my inspection have not found rj4� eu�tdenceyof,�UryeaftFormaldehyde Foam Insulation r(UFFI) , + :t .�7 s� �i ?;�a e 'Sf �4,r4`� fit{ �, ;+ �,, :;r c . ''�, v {rg y +kqi. �, y �"n , ' , .i +5 wQJ P p,��«A$-�'��; :ny . 1 x '?. �� 'Ld:�'1'��14L�°`�"¢��+�..M1•T��iG..S7"i..t.. ,.).ts•:,rl. ... - .:1 ` p � � \7 v� 5 � r ��t`✓!r��`<``� �S fat r t -`f 's,, `� s� 1�E �¢rr�� r�I'�H`��'f�,+4+�4 y�rrxtrdvl��+"-,�, ++ o- rt + ti'•"• � + ` s+.• ! ! r,��r�.''r��`te,S+'`"'�a�.��y'�`X�rrrtq�I,k('�Z�•:'�'1`t"`+Nflvv� `5 C 't s'. f t �4r x d. 2 � a :��,4•;�d , �k5 F'�r YES J� r} rTs�7 .J f � .. + g- J .tr�'ky„�� yyy,�} „t+`:Yl"`� Oi M A�..✓.�.+ �* !'t ! !� i 1" !C�^`�f'-�t .a��3t� +vi'•�'i�r r4 j r Y 4 INSPECTOR UFFIt P®Box 1347 , �r c� j c"'y r �5y ¢6 v a d ++ ..+ + � s �"4J4�", ) t �Y 1� n ��FrY?,s a 1 v• ' Brewster MA'02631;° R t "�r; 5;.. s •-' �,�XRit� *a t�'r�p��,y ?�' --j ik�'1 i r{�14'e ti+-er^a '_ 4 .-- s. �.' r< r P s � ' j' �1-800-343=4777 +t f r in .,s✓'SEAYt r b5 !'" tr r9i•yq n ♦ B .� - �F ✓��r't �i t�f f��l��t� � J�"1J�U!^{�v Aa (�'!it c �'�<j }'�� '"+Ym t:;�� r� °Ae F, •r tt,��*",Y t'>4at§' Y� r?r 3 G� Y 1 � +' s T r M •<. e l�, r a G tix" �' - tr i4 S tag `<SS °{� .. }. `,4 #j�,fA'T�t � �' ` ��'�✓ilin""�`��o-1tR Ri J r t r � w�t�. to i-f .1" ` .e a c '-' 1 y�i �,a�'OY117 1 + }$�v�1•k� �trp�� }c Eft ,, a�t t r t:Y a ss, tD d ,,�' ` i it'stctl'r vrx +5 4kni t+?•T4 ,� ! +• r Sri :r i"fiV�.SP. I_. + - .......:....,...--......��. ,.,...W.�.�«.+w•.�-...gip !'' , •.� :+..v. .�. ... ...:. .... m.«vsra..:w.bay. a...w....w..a..o.•,..,,«.r..,:.�«a .-. _...------ __...___.._-�i;:/ Page of AREAS WIIERE LEAD PAINT OR OTHER LEADED MATERIAL HAS BEEN COVERED AS A LEAD ABATEMENT METHOD. INTERIOR Side Surface or Fixture Type of Covering Room No. "(M(ndiuied on Wlid Inspec6m Report) �� C C ' Alll rSrGdP LC�s� ([n Ct c' rC� 3 G qlb 3 �1 �..rcps�+ C< Ncisrw r Fr'f i( A ECc 1f Q Sfv `•w 1!6'��b� Re•:u a+.c� .l c�'u�4ec( WET (i C is ! t'e ( c[9 cJ / •e CX EXTERIOR Side Surface or Fixture Type of Covering / nn QIA �>be w C �<wC4P f) .�ct d 4 Sr�'c `t.^+ /�c �1�ar r l6 c+ �r c(' SC•`4'A C4 X`� Pca ment Due Upon Recei t K statement Plea e p Date ir _ ��__ Services Rendered on the S � To 14-it e L i>,� S Property Inspected at Adress Adderss City uw�_� — City ^ �%Gl6Uc(��.� �- /�,Q Account dumber _ ❑ Lead Inspection ❑ REPORT TO FOLLOW ON ❑ Extra Rooms RECEIPT OF PAYMENT '❑_ /Out Buildings _ CAPE COD J" Reinspections RUILDINC Keep this as your receipt. ❑ Express Mail INSPECnM Make check payable to: ❑ Richard Davis 1230 Newtown Road Amount Due Cotuit, MA 02635 OFFICES LOCATED AT Y1230 New town Road,Cotuit,Mass. 02635 Richard Davis 508-420-0260 33 Church Street,West Dennis,Mass. 02670 RobertJ. Beaulieu 509-398-9387 1580 Route aA, Brewster,Mass. 02631 Wiiliarn Bush 508-896-7341 ---- - teaaeu mareriars icriiaiiis �� pa0L . Lj.,., Lim, which were covered as an abatement method to achieve compliance, if applicable. * Notes: Sincerely, Not Valid ,u.dWithOut ** As of above date of regulation it will be the responsibility Inspectoi Seal of the owner to be aware of any future changes in the law. Report# Registration No. INSPECTION AND ABATEMENT HISTORY IT e U o % S Name and Regis ation Number of Inspector Who Preformed Initial Inspection Date of Reoccupancy Reinspection Name and Registion Number of Inspector (if applicable ) Who Performed Reoccupancy Reinspection Name(s) and Certification or Licence Number(s) of Department of Labor and Industry Authorized Deleading Contractor(s) Who Performed.Abatement: 1 - i , . . dam TOWN OF BARNSTABLE BOARD OF;HEALTH ARTICLE It:MINIMUM STANDARDS FOR HUMAN HABITATION Date Owner W o Tenant Address Address 6 f i Y 2"Q-11 -�i'/� ' Compliance Remarks or Regulation# Yes No Recommendations 2. Kitchen Facilities 3. Bathroom Facilities A. Water Supply / 5. Hot Water Facilities 6.' Heating Facilities 7. Lighting and Electrical Facilities 8. Ventilation 9. Installation and Maintenance of Facilities 10. Curtailment of Service 11. Space and Use 12. Exits 13. Installation and Maintenance of Structural Elements 14. Insects and Rodents , . 15. Garbage and Rubbish Storage and Disposal 16. Sewage Disposal / H sing 17. Temporary PART II I 37. Placarding of Condemned Dwelling; Removal of Occupants;Demol0io �1Y�� / Person(s)In ervigwed Inspector If Public Building such as St/ore or Hotel/Motel specify here Hoes$&WARR[N,INC. - • - '0--i 1 0:43 HI'1 1 I NC. 1 157 OLD STAGE ROAD CENTERVILLE, MA 02632 (5.08) 428.1105 ABATEMENT COMPLIANCE INVOICE To,': Whom It may Concern: parry Kevorkian We."° have abated the surfaces cited by T in``;,:a Lead paint Inspection, conducted on --2-08-92 to.';w'he property located at; S Mass. Lane, Hyannis, t y4 Eby; =---Mr. Wayne Zervis s contract price is: $195.0. 00 F1" " 41.4= 4bate:nent was done in dull compliance with The Depart. of bor and Industries requlationo 454 CH 22 . 00 and The yartment of Public Health regulation X05 CMR 464 . 160 , items rough (D) including the specified use of a HEPA : i' .,_ere d vacuum. 1 t 5-2 / -92 w: Pa,-rick L. Cassidy n= _.. • -- L i c e n s e N o . D C 000645 ------- Dele.a Date der r . . M66,0%�» HYE=TECH p g 1 of— INSPECTOR LEAD INSPECTION SERVICE, INC. METHOD USED LEAD PAINT TESTING & CONSULTING X-RAY FLUORESCENCE TESTING, In NA 2S H.U.D. & MASS. DEPT. OF PUBLIC HEALTH APPROVED METHODS Expiration date lIN s- � X-RAY Registration I ,//1�6 CJ FLUORESCENCE P.O. BOX 635 WEST HARWICH, MA 02671 (508) 430.2244 1 800-698.3384 Model AqIc Serial 1 Address g. APT/ 6171 1 SINka lob I I LIMP I I I I I I I I I I I � ' CITE OWNER'S NAME: OWNER'S'ADDRESS: Pb = lead cov = covered REMARKS: Neg = Negative scr scraped Pos = Positive rep = replaced no = not accessible rev = reversed comp = compliance FLOOR 1 1L00R 1 C C g — D B ell 01 A (STREET SIDE) A (STREET SIDE) Pb'MORE THAN 1.2 mg/cm 2 with x-ray fluorescence or positive with Na,S is ILLEGAL. - _ COMPLIANCE DATE t: I IT INSPECTOR INSPECTOR V ti t1 1 Fv `' f ° HYE TECHYT '' LEAD',INSPECTION SERVICE, INC. INSPECT ,R•s > . LEAD PAINTJESTING & CONSULTING X-RAY FLUORESCENCE TESTING runs *�. H.U.D. & MASS. DEPT. OF PUBLIC HEALTH APPROVED METHODS k ; ^;� k. �'v1 �C '!i P.O. BOX 635 WEST HARWICH, MA 02671 � of_ q a pt (508)430.22" 1 800.698.3384 pg Registration�fi' A1?11N1".s ot,IN,IYI 111t1N to " AM r aY S'iC PSL < / (Ay E,XTER10R GAR t GE Comp Comp ' I_ Comp Comn SOURCE. Pb •Loose" Dete Method SIDE RISOURCE t _ Pb Loose Oats Method ;y Sidm +: * Siding 9 _ Diipboardn Dripboart� '•; Slu_rt rs,, 1 Skirt G rti—,. jCornerboards. a ornerbo rd` i 41_i '#'Doors tt ' t — �(•� poor DooryCasing%Jamb 4/ oor Casj g%Jamb rn'}' =I Thresho[C!4`-. threshold j oor -0o6r'CasinglJamb /, oor Casing/;Jamb ;T.hreshold'E`K _ 0.1 1hreshold. I i «'.W in,dow Sill A V�indow ill 'I `" Window'Cesing'i lqf�+-rvi f.t indow Casing 4} 1Nindow';Sash/Mullions Sa ¢" indow S sJ,Mullions I ` V�Iindow;Sill 'A�f�lilz; f ndow Sil' ' WndowC sing j ' Window'Sash/Mullions �� Txy Wi dow S h%Mullions � `�� Window+Sill -0 Wi.dow Sill WindowCasing 1- Wi dow Casing ,Window'Sesh/Mullions I.T-) f Win ow Sash Mullions Window;;Sil lyy-,,csle 5 P f- Win ow Sil Window�Casing�if /�i a a Win ow Ca in i Window.-Sash/Mullin pSrAga ti a Win ow Sa;h Mullions g *�s UPper':Trim ay, /n! UPP r Trim 1 �A r•CellarkWiidow Units — 0 Cella Wind Units r :CellarKWindow Units Cella,Windpw}Units I CellarrWindow Units - Cellail Windo 1 Units 'Cellar;Window Units'` Cellaill Windo Units r, 8atkhead e; �'- Bulk 'ead ') — -- Fences 1 1 Foundation` t t• � �. Foun ation f I, ' op, ;0p--.` sisY i Y, +Y Y • t ':fAi4�fiY#n�fe'S' 34 y� - ,Y'r 777 a „t ' ` PWMORE THAN 1.2 Mg/CM2 with x-ray fluorescence or .positive with Na,S is ILLEGAL. REMARKS ''*:, t� x t• z _—� r INSPECTOR In"Metion Date _1 J- y t { t�r.,t d kst� -- - HYE-TECH INSPECTOR; LEAD INSPECTION SERVICE, INC. ' LEAD PAINT TESTING & CONSULTING X-RAY FLUORESCENCE TESTING H.U.D. & MASS. DEPT. OF PUBLIC HEALTH APPROVED METHODS P.O. BOX 635 - — =— WEST HARWICH, MA 02671 (508) 430.2244 1 800-698.3384 pg. - of Registration f ADDAt SS(It INSPECTION APT / cltY ROOM N j R Co Com mp ' p SIDE SOURCE ,Te Pb Loose Detep Method SIDE SOURCE Pb Loose D.t. Memod Upper Walls ! Q,/ indow Sill/Apron Lower Is indow Casing/Header/Stops Cbeir-rail I Andow Sash/Mullions d Ex erior Sill/Parting bead area f— Door 0.0 Wi dow Sill/Apron /Q Door Casing-Jamb O'f Wi dow Casing/Header/Stops Door Win ow Sash/Mullions Door Casing-Jamb P. Exterior Sill/Parting bead area A Door /N l-D L 7- [9.f `'` /� Exterior Side Sashes 7r/ /q Door Casing-Jamb 0`151 Closet Walls Window Sill/Apron ,thrr Closet Door-Interior _> Window Casing/Header/Stops /4lV_ Closet Casing-Jamb" ~^ Window Sash/Mullions i4 Closet.Beseboa'rds Exterior Sill/Parting bead area C /9 Closet Shelves Window Sill/Apron (J Floor ( 1J Window Casing/Header/Stops •Ceiling !N/7 Window Sash/Mullions T10 �i`� Exterior Sill/Parting bead area -- , ndow Sill/Apron W dow Casing/Header/Stops �— ,W dow Sash/Mullions Ex rior Sill/Parting bead area ROOM r W V i dow Sill/Apron �- W dow Casing/Header/Stops Lr Upper Walls i Wi ow Sash/Mullions Lower-Walls Ext for Sill/Parting bead area Chair-rail, 14/L- Exterior Side Sashes `'D✓ •,- Baseboard Closet Walls -- Door Closet Door-Interior Al Door Casing Jamb Closet Casing-Jamb Door -- C (,° Door Casing-Jamb (• 1. -•^ �y 0 Closet Shelves oor . Floor D or Casing-Jamb Ceiling AIT r11 Window Sill/Apron Window Casing/Header/Stops ~ Window Sash/Mullions 1 ( Exterior Sill/Parting bead area @O I D Window Sill/Apron F—�--- - /� Window Casing/Header/Stops L_ ROOM I Q Window Sash/Mullions /� Exterior Sill/Parting bead area AIL Upper Walls G7 / 'indow Sill/Apron Lower Its indow Casing/Header/Stops CFiaiF-pdilVAndow Sash/Mullions r Bated Ex rior Sill/Parting bead area Door Wi dow Sill/Apron Door Casing-Jamb -- Wi ow Casing/Header/Stops Door — Win ow Sash/Mullions Door.Casing-Jamb _ (J. __ Exterior Sill/Parting bead area -Poor i1 Exterior Side Sashes Deer-C11sIhg-Jamb __ Closet Walls Window Sill/Apron Cl set Door-Interior Window Casing/Header/Stops CI t Casing-Jamb A Window Sash/Mullions W4; Clo et Baseboards Exterior Sill/Parting bead area e 6), Closlit Shelves Window Sill/Apron Floor n - Window Casing/Header/Stops 0, 7 Ceiling , Window.Sash/Mullions Exterior Sill/Parting bead area Pb MORE THAN 1.2 mg/cm' with x-ray fluoresc®nce or positive with Na2S is ILLEGAL. REMARKS ,-- �1NSPECTOR Inspection Dete HYE-TECH LEAD INSPECTION SERVICE, INC. ' INSPECTOR/AGENCY LEAD PAINT TESTING & CONSULTING X-RAY FLUORESCENCE TESTING H.U':D. & MASS. DEPT. OF PUBLIC.HEALTH APPROVED METHODS `. P.O. BOX 635 WEST HARWICH, MA 02671 r6 U (508) 4302244 1 800.698.3384 pgof Registration If /J! ADORISS Or INSPECTION APT. F •' City KITCHEN PANTRY Comp Comp Comp Comp SIDE SOURCE__ Pb Loose Date MatAod SIDE SOURCE Pb Loose Date Methoe I tL. Upper Walls _--- �• _— Upper Walls -- - La+wer-bWls ---_ _ — — — ower Walls hair rail gase�o2ltd B seboard Door d D or Door Casing-Janib I& D r Casing-Jamb Q Door & — Do r I Door Casing-Jamb Doi Casing-Jamb Door to Win ow Sill/Apron Door Casing-Jamb Q Win w Casing/Header/Stops pe Wind w Sash/Mullions Deaf►6esing-Jamb Exteri r Sill/Parting bead area Exterio Side Sashes QpeF,Casing-Jamb 'Upper abinets gepF Upper Cabinets Walls sing-Jamb Upper Cabinets Shelves _ W idow Sill/Apron Lower C binets W idow Casing Header;Stops Lower Ca inets Walls W_idow Sash/Mullions - _ _ Lower Ca inets Shelves t x rior Sill/Parting bead area Shelvesi dow_Sill/Apron Drawers r Wi dow Casing:Header/Stops Floor Wi dow Sash/Mullions Ceiling %.Ext rior Sill/Harting bead area Win ow Sill/Apron i Win ow Casing,_Header/Stops Win ow Sash/Mullions V! &Sill/Parting bead area BATHROOM Exte or Side Sashes /L Upper Cabinets -- I Upper Cabinets Wall Upper Walls , Upper Cabinets Shelves -- Lower-Walls Lower Cabinets ChTfR rail {i Lower Cabinets Walls' Baseboard la Lower Cabinets Shelves A Door ~_ Shelves oQ Door Casing-Jamb r^_ Drawers __ _ -^ Dclor Closet Walls - — .,=- D or Casing-Jamb Closet Door Interior -__ - _ —_ — Wi ow Sill/Apron I Closet Casing-Jamb _ — Win ow Casing/Header/Stops I- Cleset'ie58bosrds Win ow Sash/Mullions �C Closet Shelves Exte for Sill/Parting bead area ` Floor p, Exte or Side Sashes Ceiling Upper-Cabtttats r - /1 Lower Cabinets Lower Cabinets Shelves �- 7 Shelves --- C! set Walls CI set Door Interior" CI t Casing-Jamb Clo t Baseboards ClosAt Shelves Floor C ' Ceiling 1AJ` Pb MORE THAN 1.2 mg/cm, with x-ray fluorescence or positive with Na=S is ILLEGAL. REMARKS Z. ' 1 SPECTOFI Impection Date 0 ' 7,< HYE-TECH LEAD INSPECTION SERVICE, INC. ' INSPECTOR LEAD PAINT TESTING iL CONSULTING X-RAY FLUORESCENCE TESTING H.U.D. 6 MASS. DEPT. OF PUBLIC HEALTH APPROVED METHODS P.O. BOX 635 / WEST HARWICH, MA 02671Of— f%f c (508) 430.2244 1 800-698.3384 P9 Registration I 14/d AIIIINI SS UI INra91'II0N'I _ API I EXTERIOR , GARAGE "7 -----'— ----- —'-- if=-- — ---r.— Comp Comn SIDE _ SOURCE Pb Loose osfep M moe SIDE OURCE ' _ Pb Loose Das Method /t Siding * �.•t r -- Siding (_ Dripboard Pripboard ` Skirt kirt r._ Cornerboards tlornerbo4dAl Door — d boor ll i Door Casing/Jamb boor Casi g%Jamb ThresholdThreshold" a Door oor �— C Door Casing/Jamb 40or Casi g/Jamb j Threshold p,t reshold T— Window Sill t//kf7".��f S indow S 1 11 Window Casing LLo:(?;Wike indow Ce'i6 Window Sash/Mullions.4krri Window S hOVlullions II Window Sill (fp j—r4 ; _d ndow Si41 J1 I ,Q Window Casing p�7pJiZ; _¢ _ _ Wi dow C rsln Window Sash/Mullions Wi dow S�$h%Mullions Window Sill Wi dow Sil; ;Window Casing Wid0ow Casing I �- Window Sash/Mullions f Window Sa h/jMullions Window Sil (f r-,o ,�_S f Y - Win ow Sil -- -�-Window Casing �+ f 4-3 t Win'ow Ca in U "Window Sash/Mullion � fAr p t- �°U✓ %Wi,,,ndowh iMullions Upper Trim /rtI'3"fl++= Cellar WiAow Units w Units Cellar Window Units 0\ w Units _ Cellar Window Units a., - Cella Wind w Units Cellar Window Units Cellar Wind w Units I 8ufkhead Bulkh ad it — fBrtieS -- Fenc4 ill Fou.ndption _-- -4 Foun ation Az,I E THAN 1.2 m /cm2 with x-ray fluorescence or positive with Na S is ILLEGAL. Pb MORE g Y R � REMARKS INSPECTOR Inspection Date i �,� E HYE-TECH pg � of— INSPECTOR LEAD INSPECTION SERVICE, INC. METHOD USED LEAD PAINT TESTING & CONSULTING X-RAY FLUORESCENCE TESTING: 0 NA 2S H.U.D. & MASS. DEPT. OF PUBLIC HEALTH APPROVED METHODS Expiration date ly.✓ X-RAY Registration I 061 Zd_ P.O. BOX 635 0/1FLUORESCENCE WEST HARWICH, MA 02671 (508) 430.2244 1 800-698.3384 Model a Serial 0 Address g APT f 41'71 ISImmyl✓� I ILI I I I I I l I I I I I I LiJ�'l�� clTv # D F qI A /7Ea. OWNER'S NAME: 7is OWNER'S'ADDRESS: P = load cov = covered REMARKS: Neg = Negative scr :: scraped 0 O p U Pos = Positive rep = replaced tJ , O r 0.�l na = not accessible rev = reversed 3. J. J J �. _,J,• , -1. .3 3 }. - �� ' comp = compliance FLOOR I FLOOR f I (STREET SIDE)A ( E A (STREET SIDE) Pb MORE THAN 1.2 mg/cm' with x-ray fluorescence or positive with Na2S is ILLEGAL. COMPLIANCE DATE INSPECTOR INSPECTOR TO OWNER: It is your responsibility to contract a licensed deleader. A complete list of deleaders may be obtained through the Mass. Dept. of Labor and Industries, (617) 727-3454. TO DEL.EADER: Every effort has been made, when making out this report, to insure that all offending areas have been Identified. However,it is possible that due to circumstances or conditions beyond our control,offending areas were missed. It is your responsibility when giving an estimate,or when doing deleading,that if there is an area that you ?:are doubtful about,or question,that you contact this office Immediately. Also,you must notify this office, in writing, before commencing deleading in this unit. Upon reinspection If all cited violations are not corrected, future reinspections are subject to a reinspection charge. HYE-TECH LEAD INSPECTION SERVICE, INC. ' INSPECTOR LEAD PAINT TESTING & CONSULTING X-RAY FLUORESCENCE TESTING .I H.U.D. & MASS. DEPT. OF PUBLIC HEALTH APPROVED METHODS P.O. BOX 635 -- � — WEST HARWICH, MA 02671 - Of (508) 430.2244 1 800-698.3384 P9 f Registration f /�f /�,t-U. oDI)RISS I» INSPtCTION API / City ROOM If Comp Comp SIDE SOURCE Pb Loose Da ep Method SIDE SOURCE Pb Loose oa,. Method 4ic Upper Walls 0.0 Win`ow Sill/Apron Louver-Watts Win ow Casing/Header/Stops Wi ow Sash/Mullions 4A4 Baseboard "" 'Ext rior Sill/Parting bead area Door /;,� /' Wi dow Sill/Apron Door Casing-Jamb -- Wi dow Casing/Header/Stops Door Wi dow Sash/Mullions Door Casing-Jamb --- Ex rior Sill/Parting bead area ,poor e' Exterior Side Sashes c -pooc.Casmg-Jamb (' Closet Walls Window Sill/Apron Closet Door-Interior Window Casing/Header/Stops Q•b Closet Casing-Jamb- Window Sash/Mullions /• 0 (' Closet-Baseboards _ Exterior Sill/Parting bead area Closet Shelves Window.Sill/Apron Floor ' Window Casing/Header/Stops Ceiling /A✓r Window Sash/Mullions ¢-10 Exterior•,Sill/Parting bead area �?�U�2 <�;,1 C �% C}• Window Sill/Apron lr�. /=c4t'o 4 Wi dow Casing/Header/Stops - W1 dow Sash/Mullions Ext for Sill/Parting bead area ROOM �. ai Win ow Sill/Apron Win ow Casing/Header/Stops ?I eQ Upper Walls Win ow Sash/Mullions Lower Walls Exte or Sill/Parting bead area Chair rail r Exterior Side Sashes .¢. " N r1- Baseboard 0,7 Closet Walls /( Door i Closet Door Interior is /h/ Door Casing-Jamb /17. Closet Casing-Jamb �- p Door 0 - Closet"Baseboards ✓' Door Casing-Jamb <1 Lz Closet Shelves -Door` Floor 0✓ Doer-Casing-Jamb Ceiling (_7 Window Sill/Apron 410 i Window Casing/Header/Stops s1 Window Sash/Mullions -- 1 Exterior Sill/Parting bead area ,(, --_- I Window Sill/Apron y -- --- L /- Window Casing/Header/Stops / Window Sash/Mullions ROOM �?. r Exterior Sill/Parting bead area h Upper Walls c/ Wi ow Sill/Apron �- Lower-Wells 8W-Ca§ing Header/Stops Chewmil W w Sash/Mullions Baseboard ,t Exteri r Sill/Parti g bead area Door - / Wind o Sill/Apr op Door Casing Jamb /,/ Window Casing/ ader/Stops Door j Windo Sash/Mul ions Door Casing-Jamb 190 Exterior Sill/Partin ,bead area Door �. . , .. �.... '®�t� +�. Exterior Side Sashes "4, �- e Door Casing Jamb >;;I i/ �, � Closet Walls 4 Window Sill/Apron e7p" /r Closet Door-Interior (?•4° Window Casing/Header/Stops Cy.6 Closet Casing-Jamb Window Sash/Mullions Closet Baseboards ft Exterior Sill/Parting bead area Closet Shelves Wjndow Sill/Apron Floor ndow Casing/Header/Stops Ceiling /,✓i ndow Sash/Mullions L J 'V'' Exlerlor Sill/Parting bead area Pb MORE THAN 1.2 Mg/cm: with x-ray fluorescence or positive with NazS is ILLEGAL. REMARKS INSPECTOR Inspection Date r• ' .mil y;7 ' -�d n�� i• - HYE-TECH LEAD INSPECTION SERVICE, INC. ' INSPECTOR/AGENCY LEAD PAINT TESTING & CONSULTING X-RAY FLUORESCENCE TESTING /. H.U.D. & MASS. DEPT. OF PUBLIC HEALTH APPROVED METHODS IX A" �, /O_k P.O. A 0 671 35 /V .�.1,_�! WEST HARWICH, MA 02671 o� y v (508) 430.2244 1 800-698.3384 P9 Registration t 45- ADDRtSS OF INSPECTION APT./ c� = g - City KITCHEN Y Comp L4Up p Comp Comp SIDE SOURCE Pb Loose Da. od SOURCE Pb Loose Da. M..eoa 1 t l Upper Walls ----- (� -- -- r Walls lis erWallC rad lr rail 11 Baseboard O 1 Bas4board I Door Doo Door Casing-Jamb v Dooij Casing-Jam' Boor- Door j Doer-8aeing-Jamb Door casing-Jarnli Wind w Sill/Apro D asi Jamb Wind w Casing/H ader/Stops Boor- Wind w Sash/Mullions Door-Easing-Jamb Exteri r Sill/Parting bead area D Exteri r Side Sash Doer6seing-Jamb Upper Cabinets DoQL Upper lCabinets Wills Door-Ebsing-Jamb Upper iCabinets Sh Ives Window Sill/Apron (�6 Lower 1,Cabinets Window Casing Header;Stops Q".$'� — Lower abinets W 11s Window Sash/Mullions Lo-w-err�abi—nets Sh Ives Et- .—__ Exterior Sill/Parting bead area -i _ Shelves —t ,0 Window Sill/Apron Drawer r0 1 Window Casing:Header/Stops "y Floor Window Sash/Mullions C0 Ceiling Exterior Sill/tIarting bead area l7 a Window- WAWon j Window C3 tng, Bader/Stops h-- Window-SIVMullions Ext • arting bead area /c. Exterior Side Sashes d,) BATHROOM /I, Uppei`Cabinets p Upper Cabinets Wall �°pt/ 4 Upper Walls f.}�rq rc Upper Cabinets Shelves _ Lower-Walls tL_ Lower Cabinets Chair-rail-— 4tL Lower Cabinets Walls / r_ _ Baseboard c >I �,4.,t_ Lower Cabinets Shelves _t0 /,I Door O, i �pol Shelves � Door Casing-Jamb r ygjL. Drawers _ n Doh Gmarryaft Door Casing-Jamb J•G - F - CIeR17176 3r'thterior -- - Window Sill/Apron Ir> S _ �C-toseYC=astfig-Jamb _ Window Casing/Header/Stops --- - CRMet•8IMoards e Window Sash/Mullions -w°- �- oset Shelves (' Exterior Sill/Parting bead area Floor �? Exterior Side Sashes FA. Ceiling / Upper Cabinets Lower Cabinets Lower Cabinets Shelves Shelve# Closet•Walls Closet-Dooranterior Closet-Casing-Jamb QOse1.Baseboards Closet Shelvps _ Floor fB-Ql,j Ceiling Pb MORE THAN 1.2 mg/cm2 with x-ray fluorescence or positive with Na2S is ILLEGAL. REMARKS - INSPiCTOR p Inspection Date_ FoRM3o HOBasa WARREN,INC.NOV.1979.1983 THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH cITY170 a �^ DEPARTMENT lU � /fl ty ADDRESS 7-96 6 TELEPHONE Addres J "` `"F7ccupan Floor i116 Apartmen o: No.of Occupants No.of Hab able Rooms No.Sleeping Rooms a- No.dwelling or rooming units %I No.Stories Name and address of owner �. x Remarks Reg. Vlo. YARD Out Bld s.: Fences: Garbage and Rubbish Containers: Drainage Infestation Rats or other: STRUCTURE EXT. Steps,Stairs, Porches: Dual Egress:and Obst'n.: �--- ❑ B ❑ F ❑ M Doors,Windows: Roof Gutters,Drains: Walls: Foundation: & Chimney: BASEMENT Gen.Sanitation: Dampness: Stairs: Lighting:. STRUCTURE INT. Hall,Stairway: Obst'n.: Hall, Floor,Wall,Ceiling: Hall Lighting: Hall Windows: HEATING Chimneys: Central ❑Y ❑ N Equip.Repair TYPE: Stacks, Flues,Vents: PLUMBING: Supply Line: ❑MS ❑ ST ❑ P Waste Line: H.W.Tanks Safety and Vent(s)? ELECTRICAL Panels, Meters,Cir.: L T ❑ 110 ❑220 Fusing,Grnd.: AMP: Gen.Cond. Distrib. Box: Gen. Basement Wiring: DWELLING UNIT' Ventil. L to . Outlets Walls Ceils. Wind. Doors Floors Locks Kitchen Bathroom Pantry Den Lhdna Room Bedroom 1 Bedroom 2 Bedroom 3 Bedroom 4 Hot Water Facil. Sup.Ten.,Gas,Oil, Elect.: Stacks Flues,Vents,Safeties: Kitchen Facilities Sink Stove Bathing,Toilet Facll. Vent.,Plumb.,Sanit'n.: Wash Basin Shower or Tub: Infestation Rats Mice Roaches or Other: Egress Dual and Obst'n: General Building Posted Locks on Doors: ONE OR MORE OF THE VIOLATIONS CHECKED ABOVE IS A CONDITION WHICH MAY MATERIALLY IMPAIR THE HEALTH OR SAFETY AND WELL—BEING OF THE OCCUPANT AS DETERMINED BY 105CMR 410.750 OF THE CODE OR THE AUTHORIZED INSPECTOR.(See Over) "THIS INSPECTION REPORT IS SIGNED AND CERTIFIED UNDER THE PAINS AND _ PENALTIES OF PERJURY." INSPECTOR";� �� TITLE � a� LSD DATE ® TIME v P.M A.M. THE NEXT SCHEDULED REINSPECTION P.M. 410.750: Conditions Deemed to Endanger or Impair Health or Safety The following conditions, when found to exist in residential premises, shall be deemed conditions which may endanger or impair the health, or safety and well-being of a person or persons occupying the premises. This listing is composed of these items which are.deemed to always have the potential to endanger or materially impair the health or safety, and well-being of the occupants or .the public. Because Chapter II, 105 CMR 410.000 through 410.499 state minimum requirements of fitness for human habitation, any violation has the potential to fall within this category in any given situation but may not do so�in every case:and 'therefore cannot be included in this listing. Failure to include shall in no way-,be construed as.a determination that other violations may not be found to fall within this category. Nor shall failure to include affect the duty of the local health official to order repair or correction of the violation(s) pursuant to 410 CMR"410.830 through 410.833 nor shall it affect the legal obligation of the person to whom the order is issued ,to comply with such order. (A) Failure to_provide a supply of water sufficient in quantity, pressure and temperature, both hot and cold-, -to -meet the ordinary needs of the occupant in accordance with 105 .CMR 410.180 and 410.190 for a period of 24 hours or longer. ; (B) Failure to provide heat as,required by-105 GMR 410.201 or improper venting or-use-of a space heater or water -heater as prohibited by 105 CMR 410.200(B) and 410.202. 1 (C) Shut-off and/or failure to restore electricity or gas. (D) Failure to supply the electrical facilities required by 105 CMR 410.250(B), 410.251(A), 410.,253(A), '410.253(B) and the lighting in common area required by 105 CMR 410.254. (E) Failure to provide a safe supply of water. .(F) Failure to provide a toilet and maintain a sewage system in operable condition as required by 105 CMR 410.150(A)(1) and 410.300. (G) Failure to provide adequate exits, or the obstruction of any exit, passageway or common area caused by an object, including garbage or trash, which prevents egress in case of an emergency 105 CMR 410.450 and 410.451. (R) Failure to comply with the security requirements of 105 CMR 41D.480(D). (I) Failure to comply with any provisions of 105 CMR 410.600 through 410.6.02 'which results in any accumulation of garbage, rubbish, filth or other causes of sickness which may provide a food source or harborage for rodents, insects or other pests or otherwise contribute to accidents or to the creation or spread of disease. ' (J) The presence of_ lead-based paint,on a dwelling or dwelling unit in violation of the Massachusetts Department bf Public Health Regualtions for Lead Poisoning Prevention and' Control `105 CMR 460.000. (R) Roof, foundation, or other structural defects that may expose the occupant or anyone else to fire, burns, shock, accident or other dangers or impairment to health -or dafety. W Failure to install electrical, plumbing, heating and gas-burning facilities in accordance with accepted plumbing, heating, gas-fitting and electrical wiring standards or failure to maintain such facilities as are required by 105 CMR 410.351 and 410.352 so as to expose the occupant or anyone else to fire, burns, shock, accident or other danger or impairment to health or safety. (M) Any of the following conditions which remain uncorrected for a period of five or more days following the notice to or knowledge of the owner of said condition or conditions: (1). lack of a kitchen sink of sufficient size and capacity for washing dishes and kitchen utensils or lack of a. stove and oven or any defect that renders either operable. (2) failure to provide a washbasin and a shower or bathtub as required in 105 CMR 410.150(A)(2) and 410.150(A)(3) and any defect which renders them inoperable. (3) any defect in the electrical, plumbing, or heating system which makes such system or any part thereof in violation of generally accepted plumbing heating, gas-fitting, or electrical wiring standards that do not create an immediate hazard. O failure to maintain a safe handrail or protective railing for every stairway, porch balcony, roof or similar place as required by 105 CMR 410.503(A) and 410.503(B). (5) failure to eliminate rodents, cockroaches, insect infestations and other pests as required by 105 CMR 410.550. (N) Amy other violation of Chapter II not enumerated in 105 CMR 410.750(A) through (M) shall be deemed to be a condition which may endanger "or materially impair the health or safety and well-being of an occupant upon the failure of the owner to remedy said condition within the time so ordered by the board of health. FORM3D Hosss8 WARREN,INC.NOV.1979.1M THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH CITYIT�OWWNN DEPARTMEN�� ADDRESS 7,9y- 6a 6�" TELEPHONE/ Address -Occupant j�j // 1 CAA- Floor 71,0 ApartmenAo: No.of Occupants / No.of Habitable Rooms No.Sleeping Rooms No.dwelling or rooming units No.Stories Name and address of owner 1 r,Qu.,K 61 Z441VI,f Remarks 6 Reg. Vim YARD Out Bld s.: Fences: 1� Garbage and Rubbish „ Containers: 1rv\ .!- ,P , Drainage (r,.M A,,,-MI. rf PA, C 6_4L�,Ce Infestation Rats or other: STRUCTURE EXT. Steps,Stairs, Porches: Dual Egress:and Obst'n.:'T(�n ❑ B ❑ F ❑ M Doors,Windows: Roof U Gutters, Drains: - 4_01� " 0 �2;" r I-A 1_1t7_f41J ,- Walls: - , Foundation: Ud t i-0.44_ Pci Chimney: a„�lBASEMENT Gen.Gen.Sanitation: Dampness: Stairs: Lighting: STRUCTURE INT. Hall,Stairway: Obst'n.: Hall,Floor,Wall,Ceiling: Hall Lighting: Hall Windows: HEATING Chimneys: Central ❑Y ❑ N Equip. Repair TYPE: Stacks,Flues,Vents: PLUMBING: Supply Line: ❑ MS ❑ ST ❑ P Waste Line: H.W.Tanks Safety and Vents ELECTRICAL Panels, Meters,Cir.: (�,1 ,5 - - ❑ 110 ❑220 Fusing,Grnd.: O,A f G,a.t erg "C3�1 AMP: Gen.Cond. Distrib. Box: 0,j p_,� Gen. Basement Wiring: -- P DWELLING UNIT- Ventil. L to . Outlets Walls Ceils. Wind. Doors. Floors Locks Kitchen f Bathroom r Pantry Den / Livina Room Bedroom 1 Bedroom 2 Bedroom 3 Bedroom 4 Hot Water Facil. Sup.Ten.,Gas,Oil,Elect.: Stacks,Flues,Vents,Safeties: Kitchen Facilities Sink Stove Bathing,Toilet Facil. Vent., Plumb.,Sanit'n.: Wash Basin Shower or Tub: Infestation Rats, Mice Roaches or Other: Egress Dual and Obst'n: General Building Posted Locks on Doors: ONE OR MORE OF THE VIOLATIONS CHECKED ABOVE IS A CONDITION WHICH MAY MATERIALLY IMPAIR THE HEALTH OR SAFETY AND WELL-BEING OF THE OCCUPANT AS DETERMINED BY 105CMR 410.750 OF THE CODE OR THE AUTHORIZED INSPECTOR.(See Over) "THIS INSPECTION REPORT IS SIGNED AND CERTIFIED UNDER THE PAINS AND PENALTIES OF�PERJURY." �� INSPECTOR` � �+�'" 1V�� TITLES �> nl� _-/U`" DATE /D�/D�S 0 O A.M.. TIME / P.M.) A.M. THE NEXT SCHEDULED REINSPECTION P.M. 410.750: Conditions Deemed to Endanger or Impair Health or Safety The following conditions, when found to exist in residential premises, shall be deemed conditions which may.endanger or impair the health, or safety and well-being of a person or persons occupying the premises. This listing is composed of these items which are deemed to always have the potential to endanger or materially impair the health or safety, and well-being of the occupants or the public. Because Chapter 1I, 105 CMR 410.000 through 410.499 state minimum requirements of fitness for human habitation, any violation has the potential to fall within this. category in any given situation but may not do so in every case and therefore cannot be included in this listing. Failure to include shall in no way be construed as.a determination that other violations may not be found to fall within this category. Nor shall failure to include 'affect the duty of the local health official to order repair or correction of the violation(s) pursuant, to 410 CMR 410.830 through 410.833 nor shall it affect the legal obligation of the person to whom the order is issued to comply with such order. (A) Failure to provide a supply of water sufficient in quantity, pressure and temperature, both hot and cold, to "meet the ordinary needs of the occupant in accordance with 105 CMR 410.180 and 410.190 for a period of 24 hours or longer. (B) Failure to provide heat as required by 105 01R 410.201 or improper venting or use of a space heater or water heater as prohibited by 105 CMR. 410.200(B) and 410.202. (C) Shut-off and/or failure to restore electricity or gas. (D) Failure to supply the electrical facilities required by 105 CMR 410.250(B), 410.251(A), 410.253(A), 410.253(B) and the lighting in common area required by 105 CMR 410.254. (E) Failure to provide a safe supply of water. (F) Failure to provide a toilet and maintain a sewage system in operable condition as required by 105 CMR 410.150(A)(1) and 410.300. (G). Failure to provide adequate exits, or the obstruction of any exit, passageway or common area caused by an object, including garbage or trash, which prevents egress in case of an emergency 105 CMR 410.450 and 410.451. (H) Failure to-comply with the security requirements of 105 CMR 41D.480(D). (I) Failure to comply with any provisions of 105 CMR 410.600 through 410.602 which results in any accumulation of garbage,- rubbish, filth or other causes of sickness which may provide a food source or harborage for rodents, insects or other pests or otherwise contribute to,accidents or to the creation or spread of disease. (J) The presence of lead-based paint on a dwelling or dwelling unit in violation of the.Massachusetts Department of Public Health Regualtions for Lead Poisoning Prevention and Control 105 CMR 460.000. (K) Roof, foundation, or other structural defects that may expose the occupant or anyone else to fire, burns, shock, accident or other dangers or impairment to health or dafety. (L) Failure to install electrical, plumbing, heating and gas-burning facilities in accordance with accepted .plumbing, heating, gas-fitting and electrical wiring standards or failure to maintain such facilities as are required by 105 CMR 410.351 and 410.352 so as to expose the occupant or anyone else to fire, burns, shock, accident or other danger or impairment to health or safety.- (M) Any of the following conditions which remain uncorrected for a period of five or more days following- the notice to or knowledge of the owner of said condition or conditions: (1) lack of a kitchen sink of sufficient size and capacity for washing dishes and kitchen utensils or lack of a stove and oven or any defect that renders either operable. (2) failure to provide a washbasin and a shower or bathtub as required in 105 CMR 410.150(A)(2) and 410.150(A)(3) and any defect which renders them inoperable. (3) any defect in the electrical, plumbing, or heating system which makes such system or any part thereof in violation of generally accepted plumbing heating,• gas-fitting, or electrical wiring standards that do not create an imaediate hazard. ()_ . failure to maintain a safe handrail or .protective railing for every stairway, porch balcony, roof or similar place as required by 105 CMR 410.503(A) and 410.503(B). (5) failure to eliminate rodents, cockroaches, insect infestations and other pests as required by 105 CMR 410.550. (N) Amy other violation of Chapter II not enumerated in 105 CMR 410.750(A) through (M) shall be deemed to be a condition which may endanger or materially impair the health or safety and well-being of an occupant upon the failure of the owner to remedy said condition within the time so ordered by the board of health. ..�:r.,_ �... 's_ .-r: ..Yr..-..+.;.�uw�..-.,+....t:_....F-.z.wo w'''"",w•.�""'^"'.`-..:^.-�v` .:rr....�;.._..�—a_f..d.r^'.'a,,. .r, FORM3o HOBasa WARREN,INC.NOV.197a1983 THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH CITY/TOWN W � 14 o DEPARTMENT � r� r ADDRESS �yTEtLEPHO�NE/ /� Address � �Occupant t �lu / l !� r Floor T1 s!� ApartmentiNo: r No.of Occupants / No.of Habitable Rooms No.Sleeping Rooms a- No.dwelling or rooming units No.Stories � 1 � J �_j Name and address of owner 1 J�.. op 4heg for Afu%j,A r Remarks Reg. Vio. YARD Out Bld s.: Fences: �r Garbage and Rubbish je IV Containers: Drainage l�^ (1r t t.aa ,.. -1r,�, •-r tnn t f t r t c_.c Infestation Rats or other: STRUCTURE EXT. Steps,Stairs, Porches: Dual Egress:and Obst'n.:-"T1$1) ❑ B ❑ F ❑ M Doors,Windows: C / ~, -1'- �i , i -7 " 4 Roof ' r� ►' 1!` ' re�v.�rri , Gutters, Drains: f- ►t P (; � �f Ag r,4 , // /1,(' A Walls: _ f m , Foundation: Chimney: BASEMENT Gen.Sanitation: 1 Dampness: Stairs: Lighting: STRUCTURE INT. Hall,Stairway: Obst'n.: Hall, Floor,Wall,Ceiling: Hall Lighting: r Hall Windows: HEATING Chimneys: Central ❑Y ❑ N Equip. Repair TYPE: Stacks, Flues,Vents: PLUMBING: Supply Line: ❑ MS ❑ST ❑.P - Waste Line: H.W.Tanks Safety and Vent(s) ELECTRICAL Panels, Meters,Cir.: a,94.4,( ij ❑ 110 ❑ 220 Fusing,Grnd.: c,4,,1 �1.�, r.f0nt.-r 1 l x '<' 4 t' { AMP: Gen.Cond. Distrib. Box: is j ' Gen. Basement Wiring: , , j�/,�s ,, rA xa DWELLING UNIT—' Ventil. L to . Outlets Walls Ceils. Wind. Doors Floors Locks „ Kitchen Bathroom 4 Pantrya Den Living Room Bedroom 1 ' Bedroom 2 Bedroom 3 Bedroom 4 Hot Water Facil. Sup.Ten.,Gas,Oil, Elect.: Stacks, Flues,Vents,Safeties: Kitchen Facilities Sink - Stove , Bathing,Toilet Facil. Vent., Plumb.,Sanit'n.: s t. r° Wash Basin,Shower or Tub: Infestation Rats, Mice,Roaches or Other: Egress Dual-and Obst'n: General Building Posted Locks on Doors: 1 ONE OR MORE OF THE VIOLATIONS CHECKED ABOVE IS A CONDITION WHICH MAY MATERIALLY IMPAIR THE HEALTH OR SAFETY AND WELL—BEING OF THE OCCUPANT AS DETERMINED BY 105CMR 410.750 OF THE CODE OR THE AUTHORIZED INSPECTOR.(See Over) "THIS INSPECTION REPORT IS SIGNED AND CERTIFIED UNDER THE PAINS AND PENALTIES OF PERJURY." INSPECTOR &.t/�1 r TITLE I G ar" ' �I ._.Lf/ } J / _ j 1 A.M. DATE ' / / /o � TIME r P.M. THE NEXT SCHEDULED REINSPECTION P.M. 410.750: Conditions Deemed to Endanger or Impair Health or Safety ! The following conditions when found to exist in residential premises, shall be deemed conditions which may endanger or impair the health, or safety and well-being of a person or persons occupying the premises. This listing is composed of these items which are deemed to always have the potential to endanger or materially impair the health or safety, and well-being of the occupants or the public. Because Chapter II, 105 CMR 410.000 through 410.499 state minimum requirements of fitness for human habitation, any violation has the potential to fall within this category in any given situation but may not do so in every case and therefore cannot be included in this listing. Failure to include shall in no way be construed as.a determination that other violations may not be found to fall within this category. Nor shall failure to include affect the duty of the local health official to order repair or correction of the violation(s) pursuant to 410 CMR 410.830 through 410.833 nor shall it affect the legal obligation of the person to whom the order is issued to comply with such order. _ (A) Failure to provide a supply of water sufficient in quantity, pressure and temperature, both hot and cold, to meet the ordinary needs of the occupant in accordance with 105 CMR 410.180 and 410.190 for a period of 24 hours or longer. F s required improper (B) Failure to provide heat a,. rec�u__ed by 105 C.*iR 410.201 or proper venting or use of a space heater or water heater as prohibited by 105 CMR 410.200(B) and 410.202. (C) Shut-off and/or failure to restore electricity or gas. (D) Failure to supply the electrical facilities required by 105 CMR 410.250(B), 410.251(A); 410.253(A), 410.253(B) and the lighting in common area required by -105 CMR 410.254. (E) Failure to provide a safe supply of water. (F) Failure to provide a toilet and maintain a sewage system in operable condition as required by 105 CMR 410.150(A)(1) and 410.300. (G). Failure to provide adequate exits, or the-obstruction-of any exit, passageway or common area caused by an object, including garbage or.trash, which prevents egress in case of an emergency 105 CMR 410.450 and 410.451. (H) Failure to comply with the security requirements of 105 CMR 4173.480(D). (I) Failure to comply with any provisions of 105 CMR 410,.600 through 410.602 which results in any accumulation of garbage, rubbish, filth or other causes of sickness which may provide a food source or harborage for rodents, insects or other pests or otherwise contribute to accidents,oi to the creation or spread of disease. (J) The presence of -lead-based paint on a dwelling or dwelling unit in violation of the Massachusetts Department of Public Health Regualtions for Lead Poisoning Prevention and Control 105 CMR 460.000. (K) Roof,''foundation, or other structural defects that may expose the occupant or anyone else to fire, burns,. shock, accident or. other dangers or impairment to health or dafety. (L) Failure to install electrical, 'plumbing, heating and gas-burning facilities in accordance with accepted plumbing, heating, gas-fitting and electrical wiring standards or failure to maintain such facilities as . are required by 105-CMR '410.351 and 410.352 so as to expose the occupant or anyone else-to fire, burns, shock, accident or other danger or impairment to health-or safety. (M) Any of the following conditions which remain uncorrected for a-period F - of five or more days following- the notice. to or knowledge of the owner .of said condition or. conditions: - 11 - (1) lack of a kitchen sink of sufficient size and capacity for washing dishes and kitchen utensils or lack of a stove and oven or any defect thit7renders either operable. (2) failure to provide a washbasin and a shower or'bathtub as required in 105' CMR 410.150(A)(2) and 410.150(A)(3) and any defect which renders them inoperable. (3) any defect in the electrical, plumbing, or heating system which makes such.system or any part thereof in violation of generally accepted plumbing heating,• gas-fitting, or electrical wiring standards - that do not create an immediate hazard. ( )_ failure to maintain a safe handrail or .protective railing for every stairway, porch balcony, roof or similar place as required by 105 CMR 410.503(A) and 410.503(B). (5) failure.to eliminate rodents, cockroaches, insect infestations and other pests as required by 105 CMR 410.550. (N) Amy other violation of Chapter II not enumerated in 105 CMR 410.750(A) through (M). shall be deemed to be a condition which may endanger or materially impair the health or safety and well-being- of an occupant upon the failure of the owner to remedy said condition within the time so ordered by the board of health.