HomeMy WebLinkAbout0031 SMITH STREET - Health 31 Smith Street, Hyannisport
A=288-013
TOWN OF BARNSTABLE
LOCATION .31 SEWAGE # Z o ao-- C3 6
VILLAGE f/;�.�.������� _ ASSESSOR'S MAP & LOT 2P.- Est 1
INSTALLER'S NAME&PHONE NO. 8h
SEPTIC TANK CAPACITY /s'oo aT
LEACHING FACILITY: (type) Ca/:a k (size) 2.8s x /0.3 x 2'
NO.OF BEDROOMS o,4�� f
BUILDER OR OWNER d AkA,-).i
PERMIT DATE: //- Z P- Zo v, COMPLIANCE DATE: 1 !3 Z b c c
Separation Distance Between the:
Maximum Adjusted Groundwater Table and 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
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• THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS
Zipprication for Mizpaal 6pgtem construction permit
Application for a Permit to Construct()4)Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. 31 far.+1- St Owner's Name,Address and Tel.No.
��yti./w�s pow V't G. 55 p0.v3L (IA-0-0 eu
Assessor's Map/Parcel 1 tt-tV- ,7 tom, f t/,.
Z 99 L0 CC,"- � o�, l4111 2
Installer's Name,Address,and Tel.No. Designer's Name,Addr ss 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 gallons per day. Calculated daily flow gallons.
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) / l n vi n-t ri�-- j e �" �'i
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 Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issned by this Board f He
Signed CZ Date
Application Approved by f Date r' ZZ5 2r��
Application Disapproved for the following reasons
Permit No. <>6�17� Date Issued
TOWN OF BARNSTABLE
LOCATION 31 s
SEWAGE„#.2eca 636
VILLAGE /(eau,„�oaeT ASSESSOR'S MAP & LOT
INSTALLER'S NAME&PHONE NO. 4.)
SEPTIC TANK CAPACITY /S'oo CsT
LEACHING FACILITY: (type) 3 C`►7�, �3v
��'dR (size)
i NO.OF BEDROOMS oJe
BUILDER OR OWNER 0 4,11 d
i
PERMIT DATE: //- z r- zo t o COMPLIANCE DATE: l L ! Z o r
iSeparation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet
i
Private Water Supply Well and Leaching Facility (If any wells exist
f on site or within 200 feet of leaching facility) Feet
image of Wetland and Leaching Facility'(If any wetlands exist
within 300 feet of leaching.facility)., Feet
�5 Furnished by
err
vo
Z
m Z. h bra 3 r
_ y $
3
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Y bI
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No: ._ Fee
N.._
Entered in computer:
THE COMMONWEALTH OF MASSACHUSETTS
Y "
f,r ,0"�) 'PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS
Zipplication for Diopogal *potem Con5truction Permit
ti
Application for a Permit to Construct Repair( )Upgrade( )Abandon( ) O Complete System ❑Individual Components
4
Location Address or Lot No. 3( 5,`%4-.( S r Owner's Name,Address and Tel.No. /?/L
a v..-s . Jn a, t i 0 4 v"a a &_0 w w t Y7 a`t d
Assessor's Map/Parcel L/ 9,7 w` `�d 4.' t t
�w... r < you. c,;; l y
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
SSI �
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 gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date
. F Title
Size of Septic Tank Type of S.A.S.
Description of Soil
A_ ,
1
�v
Nature of Repairs or Alterations(Answer when applicable)- u ►'/^--1.
Date last inspected:
Agreement: 3
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 Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been is ed by this Boar v
f He h.
Signed C _. Date — Z 00
Application Approved by r Date A0'` Z6
Application Disapproved for the following reasons
Permit No. 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 6 n;- .., k t rrs r: , y
at 31 `"1: t 4 S t. 11 4 r.• n. t s .3 has been constructed in accordance
with the provisions,of Title 5 and the for Disposal System CoiVstructii5n PermAdEbA0 OY �dated./WW " ►
Installer Designer s A
The issuance of this permit shall of e�. ,nq''-trued as a guarantee that th ys ewwill functio17,6
de i id, �
Date ti 7110 Inspector�1��.�
r
001
_ _ _
No. � ------—-----------=-------Fee �.
�'. THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS
lwi�pogar Opotem Conotruction Permit
Permission is hereby granted to Construct(X)Repair(k'' )Upgrade( )Abandon( )
System located at A),l 4 :v J 5
and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to
comply with Title 5 and the following local provisions or special conditions.
Provided:Construction must be completed within three years of the date of nrmit.
Date: // F" 'tip Approved b,
y 1/6/99
NOTICE: This Form, Is To Be Used For the Repair Of Failed
Septic Systems Only.
CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL
WORKS CONSTRUCTION PERMIT (WITHOUT DESIGNED PLANSI
hereby certify that the application for disposal works
construction permit signed by me dated , concerning the
property located at meets all of the
following criteria:
• This failed system is connected to a residential dwelling only. There are no commercial or business.
uses associated with the dwelling.
• The soil is classified as CLASS I and the percolation rate is less than or equal to 5 minutes per inch.
• There are no wetlands within 100 feet of the proposed septic system
• There are no private wells within 150 feet of the proposed septic system
• There is no increase in flow and/or change in use proposed
• There are no variances requested or needed.
• The bottom of the proposed leaching facility will not be located less than five feet above the maximum
adjusted groundwater table elevation. [Adjust the groundwater table using the Frimptor method when
applicable]
• If the S.A.S.will be located with 250 feet of any vegetated wetlands,the bottom of the proposed
leaching facility will not be located less than fourteen(14)feet above the maximum adjusted
groundwater table elevation,
Please complete the following:
A) Top of Ground Surface Elevation(using GIS information) to
B) G.W. Elevation +the MAX. High G.W. Adjustme t.
DIFFERENCE BETWEEN A and B o
SIGNED : DATE:
[Please Sketch proposed plan of system on back].
NOTICE
Based upon the above information, a repair permit will be issued for bedrooms maximum. No
additional bedrooms are authorized in the future without engineered septic system plans.
q:health folder:cert
TOWN OF BARNSTABLE
LOdATION ST ��ro wT� SEWAGE#
Sr��TY\
VII.LaGE .�-�-�5 u�c'C"' ASSESSOR'S MAP& LOT • d
INSTAi LER'S NAME&PHONE N0.
I SEPTIC TANK CAPACITY / S4y Si T
LEACHING FACILITY: (type)
NO;QF'BEDROOMS_
BUILDER OR OWNER aL7-1
PERIkITI'DATE: COMPLIANCE DATE: /3"J
iSeparation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility
Feet
Private Water Supply Well and Leaching Facility (If any,wells exist Feet
on:siie:or within 200 feet of leaching facility)
Edge'of.Wetland and Leaching Facility(If any wetlands exist Feet
i witliin.300 feet of leaching facility)
l
Furnished by
q 0
fY� Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS
Zi pplication for niopoe al *p5tem Con truction Permit
Application for a Permit to Construct( )Repair(�pgrade( (tAbandon( ) Complete System ❑Individual Components
Location Address or Lot No. T �114#111
owner's Name,Address 9d Tell.No. A
Assessor's Map/Parcel
Ins, er's Ngme,Address,and'l el.No S ��� Designer's Name,Address and Tel.No.
Type of:Building:
Dwelling No.of Bedrooms� Lot Size sq.ft. Garbage Grinder( )
Other Type of Building IZS, No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow 3 3 L gallons per day. Calculated daily flow 3 gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank �S� Type of S.A.S. 4 e&ao! p
Description of Soil
Nature of Repairs or Alterations(Answer when applicable) / S�T' 1�0? V/
'v�,T r 1.T t'�T'y►2 S 3�S'0�11� i io yyG�vr�:� IV" uA
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 Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issued by this Board of Health.
Signed AD Date
Application Approved by Date
Application Disapproved for the following reasons
Permit No. '— Date Issued
.013
o , Fee _
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
_g
- Yes
P BLIC.,HEALTH DIVISION -TOWN OF.BARNSTABLES MASSACHUSETTS
01p�pr ration for Zigpo�aY' *p#tem clConotruction Permit
Application for a Permit to nstruct( )Repair(t/ pgrade,( dAbandon( ) Complete System O Individual Components
Locatio Address or Lot No. a I'5 M% S � er's Name,Addre00
ss TellrTo.
L
Assessor's Map/Parcel
In er's N Address and el.No. Svc Z'� �; Designer's Name,Address and Tel.No.
f a
Type of Building v i., ✓
Dwelling No of Bedrooms Lot Size." sq.ft. Garbage Grinder(. )
Other` Type of Building 2e-�5 , No.-off P6rsons Showers( ),Cafeteria( . )
Other Fixtures
Design Flow- 3 3 _ gallons per day.,Calculated daily flow ' gallons.
Plan Date Number of.sheets' Revision Date
Title r'Z� IZf J
Size of Septic Tank / Type of S.A.S. / ��5 C�l�/o
-Description of Soil liliZ e' r q N
;4 S,T, fD_
Nature of Repairs or Alterations(Answer when applicable) ' "�J �
1n fir(.►vT'DY(S 'c.r��3�.STliV� i.vyUv' /V/l
Date last inspected
r Agreement
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in`accordance with the provisions ofTitle S of the Environmental Code and not to place the system in operation until a Certifi-
cate '
'of Compliance has been'issued b this Board of Health.
Signed ch k. Date
Application Approved by V Date
Application Disapproved for;the following reasons
6 11 Permit No. Date Issued :o
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE-MASSACHUSETTS
i
�. . _ `pert firate.of Compliance
THIS IS TO.0 TIFY, that the On`'site Sewagg Disposal System Constructed( )Repaired( )Up tided(
Abandoned( )by .o`os —C E✓ SC(f i y
v%YN J vY
;at e' � en constructed in accordance
With the;provisions of Title 5 and the for ispos System Construction Permit No. .. dated
:Installer Designer
The issuance of this permit shall not be.construed as a guarantee that'the system ill function as designed. .
Date Z� R Inspector3
� r k15::i ��'':tTr,.w� �.#. ,� # r,�;.,w.v.ey-,, .; +r�Na�+yw...�;,�, b t;• � �h, '� raw�" `-* � 'v. „ -
No. Fee
} THE COMMONWEALTH,OF MASSACHUSETTS
- PUBLIC HEALTH DIVISION - BARNSTABLE}MASSACHUSE i7S
g ogar pgtem- ongtruction Permit
Permission is hereby:granted'to Construct( )Repair( Upgrade( )Abandon( )
Sysfem"located at 3 l � -K7 S-1"`.i tU o1_ :� h t S N ot�'
and as described in the above.Application for Disposal System Construction Permit. The applicant recognizes hi er duty to
comply with Title 5 and the following local provisions or special conditions.
D p ,'
Provided:Cons 'on u7specp—&ted within three years of the date of t s,erm-t
I
Date:
E Approved by
f
-� -: 1019197
NOTICE: This Form Is To Be Used For the Repair Of Failed
Septic Systems Only.
CERTIFICATION OF SKETCH AND APPLICATION PERMIT (WITHOUT
DISPOSAL WORKS CONSTRUCTION
ENGINEERED PLANS)
hereby certify that the application for disposal works
construction permit signed by me dated � '-�-
�Q ,concerning the
property located at ? S Vwf� ST, y ° meets all of the
following criteria:
0 There are no wetlands located within 100 feet of the proposed leaching facility
There are no private wells within 150 feet of the proposed septic system
l4/T sere is no increase in flow and/or change in use proposed
There are no variances requested or needed.
the
Z- 1f the proposed leaching facility will be located less than fourteen(14)feet above the maximumfeet of any wlans,the bottom adjusted
adj sled
proposed leaching facility will�be located
groundwater table elevation. S.4,5 3 t ��.
j� b\ -,oV� o� If-bt -e—
Please complete the following: ------------
,
A)Top of Ground Elevation(according to the Engineering Division G.I.S.map)
B)Observed Groundwater Table Elevation(according to Health Division well map)
SIGNE7: : DATE:LICENEPTI SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER
[Attach a sketch plan of the proposed system.Also if the licensed installer posesses a certified plot plan,
this plan should be submitted).
q:health folder:cert
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TOWN OF BARNSTABLE ,
LOCATION ,�t ena� CErd �� SEWAGE # -"
VILLAGE ASSESSOR'S MAP & LOT V't D 13 f
INSTALLER'S NAME&PHONE N0. �� dl' .SP7 C
SEPTIC TANK CAPACITY / -5,T
LEACHING FACILITY: (type)6 7 (size)
NO.OF BEDROOMS
BUILDER OR OWNER [ ►� �AVi� 1frf��
PERMIT DATE:_,�_'��- g� COMPLIANCE DATE:. /3—
Separation Distance Between the:
i
Maximum Adjusted',Groundwater Table and 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
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r}T(��p�;�}� ?i�y
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_ TOWN OF BARNSTABLE .y n
LOCATION � i Sr � `� SEWAGE #
VILLAGE ��^ �� old ASSESSOR'S MAP & LOTS c{
INSTALLER-! NAME&PHONE NO. Itio—G69jote S�/Ti�•
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type).
s� �
NO.OF BEDROOMS
N�.-BUILDER-OR OWNER
PERMITDATE: a.l COMPLIANCE DATE: "' I
"> Separation Distance Between the:
Maximum Adjusted Groundwater Table and 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
e
dZ
O -
41 J
/)L; 0/3
Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: k
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS
2pprication for Mir o Y *pgtem Co 5truction Permit
Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) Complete System El Individual Components
Location Address or Lot No. sl'VI V4.k 5f ear- Owner's Name,Ad ess and Tel.No
Assessor's Map/Parcel --e Va
In/stal'l�er's N e,Address,and Tel.Nrc�
o. ZE—( Designer's Name,Address and Tel.No.
T_s.
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 f gallons per day. Calculated daily flow gallons.
Plan Date �� ' Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S. / 6
Description of Soil
47
Nature of Repairs or Alterations(Answer when applicable) UC/ 71 y Zt/ 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 Environmental Co5le and not to place the system in operation until a Certifi-
cate of Compliance has been issued by this Bo a lth. 11
Signed Date 0�7/91?
Application Approved by r j Date
Application Disapproved for the following reasons
Permit No. Date Issued IlHal
TOWN OF BARNSTABLE
'LOCATION
SEWAGE# -
VII.LAGE a ASSESSOR'S MAP&LOT " 1
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY J
LEA CHING FACILITY: (type) �A i l�ki�d(size) r[�
NO,OF BE;ROOMS
BUILDER OR OWNER
1 - 9A
, .PERMTTDATE:
COMPLIANCE DATE:
j: Separation Distance,
Between Feet .
s.
I .:'::...Maximum Adjusted Groundwater Table and Bottom of Leaching Facility
any
wells exist
? private.Water Supply Well and Leaching Facility .(If Feet
f' on site or within 200 feet of leaching facility)
'; Edge of Wetland and;Leaching Facility(If any.wetlands exist Feet
within 300 feet of leaching facility)
`;-Furnished byJ
CUT'("
�
;
t( 1
' �} I
N�7Fee
rY' ?p f TH9COMMONWEALTH OF MASSACHUSETTS _ Entered in computer: -
'' Yes
— — ----= PUBLIC HEALTH DIVISION -TOWN aOF BARNSTABLES MASSACHUSETTS
,r
Zipprtcation for Df� o ar 6pgtem- Co 5truction Permit
Application for a Permit to Construct( )Repair( Upgrade( )Abandon( ) Complete System ❑Individual Components
Location Address or Lot No. 3/sl'V).d� 5 j ea — Owner's Name,Address and Tel.No.
— C,K�,
Z
Assessor's Map/Parcel G 0 1-5
Installer's Name,Address,and Tel.No o. S 7 7&—(�`� Designer's Name,Address and Tel.No.
��—
3 O
oc=WT
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 C gallons per day.",Calculated daily flow 3 4' gallons.
Plan Date 2-' Number of sheets Revision Date
Title C 1 i
Size of Septic Tank /t Type of S.A.S. i
Description of Soil
Nature of Repairs or Alterations(Answer when applicable) /7 s/,
L G.%✓Jl i T ,_ ���i'lti�
v _y 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 Environmental Code and not to place the system,in operation until a Certifi-
cate of Compliance has been issued bZ this B oaijj&f He lth. �� --,_ •
Signed `� Date
Application Approved by Date
Application Disapproved for the following reasons
Permit No. Date Issued '
—————— ————— ——.———————.———————- —------
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
Certificate of Compliance
THIS IS TO CERTIFY that the Oik5ite Sewage gisposalAystem Constructed( )Repaired( )Upgra d(�
Abandoned( )by =P-r [
at 31 S k a enrk- has ben constructed in accordance
with the provisions of Title 5 and the for Disposal *stem Construction Permit No. dated
Installer Designer ,.
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
Date - 13 -9 F Inspector Q'>7
d,
- -- -----------------------------------
No. Fee
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION — BARNSTABLES MASSACHUSETTS
Migool *p5tem Construction Permit
Permission is hereby granted to Construct( )Repair(/Upgrader,(y )Abandon( )
System located at 3 1 S l� ( S c " h C VC,
y�
and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to
comply with Title 5 and the following local provisions or special conditions.
Provided:Construcftn/must be come leted within three years of the date of th ' fJ 1
Date: / ! ApprovedY b 7 ( A- 0
I / V ly C 1 v r / y
10/9/97
NOTICE: This Form Is To Be Used For the Repair Of Failed
Septic Systems Only.
CERTIFICATION OF SKETCH AND APPLICATION FOR A
DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT
ENGINEERED PLANS)
hereby certify that the application for disposal works
construction permit signed by me dated a1``7 , concerning the
property located at l SW` s� ��� �0 2� ��`"`�� meets all of the
following criteria:
There are no wetlands located within 100 feet of the proposed leaching facility
There are no private wells within 150 feet of the proposed septic system
There is no increase in flow and/or change in use proposed
,*-,,"There are no variances requested or needed.
'-Zlf the proposed leaching facility will be located within 250 feet of any wetlands,the bottom of the
proposed leaching facility will W be located less than fourteen(14)feet above the maximum adjusted
groundwater table elevation. i
� S.�
a�Tvr� a� ,5,
Please complete the following: _
A)Top of Ground Elevation(according to the Engineering Division G.I.S.map)
B)Observed Groundwater Table Elevation(according to Health Division well map)
SIGNED: DATE:
LICENSED SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER
[Attach a sketch plan of the proposed system.Also if the licensed Installer posesses a certified plot plan,
this plan should be submitted).
q:health folder:cert
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TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION
Map �$� Parcel Q.J 3 Permit# 117�
Health Division 9 494/4PIW 1 ,,4b��ri�y� n 'L. s<,� Date Issued t ! 2—
Conservation Division i
Fee: r
Tax Collector..
Treasurer D ' ? SEPTIC SYSTEM MUST E
i INSTALLED IN GO
MPLIATICE
j Planning Dept. � � .i ! � WITH T1TLE
RONMENND
TAL CODE I
ENVI
Date Definitive PIanApproved by Planning Board TIONS
i i TOWN REGULA ,
Historic-.OKH 0< Preservation/Hyannis
Project Street Address 3 t S e-f ;
illage 1-4 ,lot N,s o,ti-c
'`Owner (� ��� ' (�►.�,,.� ! Address y`I�,7 MDDL ! ��r s �,;•.� 2�
Telephone i 71 (o 4 y- �2 y 7 C��.,a"J.". V CL 141
;Permit Request (� l -�1 1 r-I1 Yyz I
q 4 a1C .+-4Ax w'_t h R.C.` (l►Wf`1.0 S'� to- 4Ga. OK
Square feet: 1 st floor: existin IV, o proposed 2nd floor:existing proposed Total new
Valuation SZ Zoning District Flood Plain Groundwater Overlay
Construction Type
Lot Size N ?
Grandfathered: ❑Yes ❑No If yes, attach supporting documentation.
Dwelling Type: Single Family ❑ Two Family ❑ Multi-Family(#units)
Age of Existing Structure Historic House: ❑Yes ❑No On Old King's Highway: ❑Yes ❑No
Basement Type: ❑Full ®Crawl ❑Walkout ❑Other S(a,b
Basement Finished Areas . ti�
( qft.) Basement Unfinished Area(sq.ft) Al
Number of Baths: Full:existing new Half:existing new
Number of Bedrooms: existing / new
Total Room Count(not including baths): existing new First Floor Room Count
Heat Type and Fuel: ®Gas ❑Oil ❑ Electric ❑Other
Central Air: ❑Yes ❑No Fireplaces: Existing New Existing wood/coal stove: Cl Yes ❑No
Detached garage:O existing ❑new size Pool:❑existing ❑new size Barn:❑existing ❑new size
Attached garage:❑existing ❑new size Shed:❑existing ❑new size Other:
Zoni29 Board of Appeals Authorization ❑ Appeal# Recorded❑
Commercial ❑Yes ❑No If yes,site plan review#
.r�;Cur►ent Use
Proposed Use
BUILDER'INFORMATION
Name nrs o t,► Telephone Number ?C z -29z 7 /
Address /G v License# Y 9
4v. �' -^ "'r'tti 4/t Home Improvement Contractor# o 2 y
U Z G Worker's Compensation# -1.00 r
ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO
SIGNATURE)Z;4� ------------------DATE
FM30� HAW HOBBSBWARRENTm THE COMMONWEALTH OF MASSACHUSETTS
�_.
BOARD OF HEALTH
CITY///TT,OW,N 4—
DEPARTMENT
/
e
h
ADDRESSi _qg q
�y SyO�`0
TELEPHONE
Address "'k Occupant 1� I/
Floor Apartment No. No. of Occupants
No. of Habitable Rooms 6 No.Sleeping Rooms_
No.dwelling or rooming units No.Stories 'Z-- 6�
Name and address of owner ,T,-a-wi^
Remarks Reg. Vio.
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: ,. cls .elf 49401�
Dampness: e -zsr z a
Stairs:
Li htin :
STRUCTURE INT. Hall,Stairwa ,,) vl , pc G✓ �'�
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.:
❑ 110 ❑ 220 Fusing,Grnd.:
AMP: Gen.Cond. Distrib. Box:
Gen. Basement Wiring:
DWELLING UNITd
Ventil. L to . Outlets Walls Ceils. Wind. Doors Floors Locks
Kitchen �1i9
Bathroom
Pantry
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.:
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
PENALTIE F PERJURY."
INSPECTO `ter TITLE11
DATE xf�7 TIME /� P•M
A.M.
THE NEXT SCHEDULED REINSPECTION P.M.
a+"Ma.:.a, �,r��+-:�+ _ s '�!"-:. .w vrR k.'' ' �f � z � � 'ry; s' �a?•'�-. 1 a.,�,,v
}.urn;,�k-,�-. ,t,,,.�i�,�y�4.J ?r �r�r'�?9+ ��.r..�zc. .�'•.uu'' �dr, s�.,� t 3';' �e,� n ��' �,'�'�`,r� j�,,. � tt.�r �1� , y.
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 heaith, or safety and well-being of a person or persons occupying the premises. This listing is composed of those
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 410.100 through 410.620 state minimum requirements of fitness for
human habitation, any other violation has the potential to fall within this category in any given specific situation but may not do so
in every case and therefore is not included in this listing. Failure to include shall in no way be construed as a determination that
other violations or conditions 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 such violation(s) pursuant to 105 CMR 410.830 through 410.833 nor shall failure to
include 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 CMR 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) Shutoff and/or failure to restore electricity or gas.
(D) Failure to provide the electrical facilities required by 105 CMR 410.250(B), 410.251(A), 410.253 and the lighting in com-
mon 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 disposal 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 any object,
including garbage or trash, which prevents egress in case of an emergency 105 CMR 410.450, 410.451 and 410.452.
(H)' Failure to comply with the security requirements of 105 CMR 410.480(D).
(1) Failure to comply with any provisions of 105 CMR 410.600, 410.601 or 410.602 which results in any accumulation of gar-
bage, 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.
1
(J) The presence of leadbased paint on a dwelling or dwelling unit in violation of the Massachusetts Department of Public
Health Regulations for Lead Poisoning Prevention and Control, 105 CMR 460.000. (See M.G.L. c. 111 @@ 190 through 199.)
(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 safety.
(L) Failure to install electrical, plumbing, heating and gas-burning facilities in accordance with accepted plumbing, heating, 1
gas-fitting and electrical wiring standards or failure to maintain such facilties 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 defect in asbestos material used as insulation or covering on a pipe, boiler or furnace which may result in the release
of asbestos dust or which may result in the release of powdered, crumbled or pulverized asbestos material in violation of 105
CMR 410.353.
(N) Failure to provide a smoke detector required by 105 CMR 410.482.
(0) 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 inoperable.
(2) Failure to provide a washbasin and shower or bathtub as required in 105 CMR 410.150(A)(2) and 410.150(A)(3)or 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, gasfitting, or electrical wiring standards that do,not create an immediate hazard.
(4) 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.
(P) Any other violation of 105 CMR 410.000 not enumerated in 105 CMR 410.750(A)through (0)shall be deemed to be a con-
dition 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.
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' 61 Endicott Street,Bldg. 32-1
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Ai rSafe Inc. Norwood, MA 02062 . 781-762-M
The Experts in Asbestos Removal
I N V O I C E
CUSTOMER: MR. J08N JOHNSON DATE: 11/03/00
ADDRESS : P .O. BOX 118 . INVOICE #: 85742
W.BARNSTABLE, MA 02668
SITE:[7HYTAN
H AVE. '
PORT, MA
PHONE: (508) 362-2871 PAYMENT DUE UPONRECIEPT OF INVOICE
WORK DESCRIPTION AMOUNT
REMOVAL AND DISPOSAL OF ASBESTOS-CONTAINING
PIPE INSULATION (APPROXIMATELY 120 LF) AND
CLEAN-UP OF THE BASEMENT AREA. $ 1 , 200 . 00
----------------
TOTAL DUE: $ 1 , 200 . 00
THANK YOU.
P 339 579 024
US Postal Service
Receipt for Certified Mail
No Insurance Coverage Provided.
Do not use for Intemational Mail See re rse
SenjA
StIA Nu er
P ice,State,&ZIP C
od= d
Postage $ ,
Certified Fee
Special Delivery Fee
Restricted Delivery Fee
N
Retum Receipt Showing to
Whom&Date Delivered
Q Retum Receipt Showing to Whom,
Q Date,&Addressee's Address
0 TOTAL Postage&Fees
CO Postmark or Date
LL
/0 30-
Stick postage stamps to article to cover First-Class postage,certified mail fee,and
charges for any selected optional services(See front).
1.If you want this receipt postmarked,stick the gummed stub to the right of the return
address leaving the receipt attached, and present the article at a post office service
window or hand it to your rural carrier(no extra charge). m
03
2. If you do not want this receipt postmarked,stick the gummed stub to the right of the a)
return address of the article,date,detach,and retain the receipt,and mail the article.
in
3. If you want a return receipt,write the certified mail number and your name and address rn
on a return receipt card,Form 3811,and attach it to the front of the article by means of the
gummed ends if space permits. Otherwise,affix to back of article. Endorse front of article a
RETURN RECEIPT REQUESTED adjacent to the number. a
4. If you want delivery restricted to the addressee, or to an authorized agent of the C
addressee,endorse RESTRICTED DELIVERY on the front of the article.
5. Enter fees for the services requested in the appropriate spaces on the front of this
receipt. If return receipt is requested,check the applicable blocks in item 1 of Form 3811. ri
6. Save this receipt and present it if you make an inquiry. a
Town of Barnstable
V Regulatory Services
rOwti Thomas F. Geiler, Director
Public Health Division
BAMSrABIZ
v� 1659. ��� Thomas McKean, Director
RFD 1A°�A 367 Main Street, Hyannis, MA 02601
Office: 508-862-4644 Fax: 508-790-6304
October 30, 2000
David E. & Barbara T. Brown
4497 Middle Cheshire Road
Canandaigun, N.Y. 14424
NOTICE TO ABATE VIOLATIONS OF 105 CMR 410.00, STATE SANITARY CODE U,
MINIMUM STANDARDS OF FITNESS FOR HUMAN HABITATION AND THE TOWN
OF BARNSTABLE RENTAL ORDINANCE, ARTICLE 51
The property owned by you located at 31 Smith Street, Hyannis, was inspected on October 6,
2000 by Glen Harrington, R.S. Health Inspector for the Town of Barnstable, because of a
complaint. The following violations of 105 CMR 410.00, State Sanitary Code U, Minimum
Standards of Fitness for Human Habitation were observed:
410.353: A suspect asbestos-containing material (ACM) was observed in the basement
(thermal pipe insulation). A licensed asbestos inspector must inspect and sample the suspect
ACM. If the material is ACM, a licensed abatement company must be hired.
410.482: The smoke detector was observed to be inoperable.
410.500: Several holes were observed in first to second floor stairwell.
You are directed to correct the violation of 410.482 within twenty-four (24) hours of receipt of
this notice.
You are also directed to correct the remaining above listed violations within thirty (30) days of
receipt of this notice.
You may request a hearing if written petition requesting same is received by the Board of Health
within seven (7) days after the date order is received. However, these violations must be
corrected regardless of any request for a hearing.
brown/wp/q/ls
t. X
Please be advised that failure to comply with an order could result in a fine of not more than
$500. Each separate day's failure to comply with an order"shall constitute a separate violation.
Renting the above property with uncorrected violations is a violation of the State Sanitary Code
and the Town of Barnstable Rental Ordinance, Article, section 6-2
PER ORDER OF THE BOARD OF HEALTH
_ as . McKe n
Director of Public Health
Enc. Gold copy of inspection report
brown/wp/q/ls
i, .. .t. _
COMPLETESENDER: COMPLETE THIS SECTION / ON DELIVERY
■ Complete items 1,c;and 3.Also complete A. Received by(Please Print Clearly) 11 Date of elivery
item 4 if REstricted Delivery is desired. `vt'. ti-, ,� ' Gd A-3
to Print your name and address on the reverse C. Signature
so that we can return the card to you. _ Agent
■ Attach this card to the back of the mailpiece,
or on the front if space permits. X ❑Addressee
1. Article Addressed to: D. Is delivery address different from item 1? ❑Yes I
If YES,enter delivery address below: ❑ No
7-/7' 97 )rzr,1A
3. Service Type
�Certified Mail ❑ Express Mail
❑ Registered ❑ Return Receipt for Merchandise
❑ Insured Mail ❑C.O.D.
0 4. Restricted Delivery?(Extra Fee) ❑Yes
2. Article umber(Copy rom service label)
dPS.FOrm 3811,fJuly 1999 t l l l�; I {DomesticcReturn Receipt 102595.00-M-0952
UNITED STATES POSTAL SERVICE First-Class Mail
.Postage&Fees Paid
`USPS
Permit No.G-10
• Sender: Please print your name, address, and ZIP+4 in this box •
N
Board of Health
N Town of ftimstable+
P O.Box 04
Hyannis,, assaohusetts 02601
I
Li
(� GG -
(t 4 cl? ��Ce_ �ke� G<cre
'f-
NOTICE TO ABATE VIOLATIONS OF 105 CMR 410.00, STATE SANITARY CODE H,
MINIMUM STANDARDS OF FITNESS FOR HUMAN HABITATION AND THE TOWN
OF BARNSTABLE RENTAL ORDINANCE, ARTICLE 5//1//
The property owned b you located at 3 1 S� `u f f�' ' 7 G
p p y y y $+rert—, , was inspected
on CC4v4_9, G , 2000 by Glen Harrington, R.S. Health Inspector for the Town of
Barnstable, because of a complaint. The following violations of 105 CMR 410.00, State
Sanitary Code H, Minimum Standards of Fitness for Human Habitation were observed:
cM 2
(,vrt,.,S o b S-L-v vt �, cL J e,.....t.•ti a— Y f .. A l f C E¢ J Ck
w�c,,! �i��.e �h 1�.!a,di vin)e
lM G t J ,/`^t iA j C` I ZXM S-e ef "ci M.`r G&_vy&17
D. 4 7 2 du4et,dvY oar 45 Lj�c
-p__�&c /V OP ,,1,4d,6, o
'1/U`
You are directed to correct thel�violation#of within twenty-four(24) hours of receipt of
this notice.
You are also directed to correct the remaining above listed violations within thirty (30) days of
receipt of this notice.
You may request a hearing if written petition requesting same is received by the Board of Health
within seven (7) days after the date order is received. However, these violations must be
corrected regardless of any request for a hearing.
Please be advised that failure to comply with an order could result in a fine of not more than
$500. Each separate day's failure to comply with an order shall constitute a separate violation.
PER ORDER OF THE BOARD OF HEALTH
Thomas A, McKean
Director of Public Health
" HOBBSBWARREN'M THE COMMONWEALTH OF MASSACHUSETTS
FORM 30 �xw ^�
BOARD OF HEALTH
CITY/TOWN
//
a DEPARTMENT
ADDRESS
,M SV0,eW
TELEPHONE
Address 3 S ` t J� 4�— Occupant^-
Floor Apartment No. No. of Occupants 01
No. of Habitable Rooms p No.Sleeping Rooms /__ � J
No. dwelling or rooming units / No.Stories Z--
Name and address of owner _
Remarks Reg. Vio.
YARD Out Bld s.: Fences:
Garbage and Rubbish F T _
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: U tvw r• ►-%
Foundation:
Chimney:
BASEMENT Gen.Sanitation: v5 0-C,-, 3 e1 it J CxziQ S 3
Dampness: d46
Stairs:
Li htin :
STRUCTURE INT. Hall,Stairway: 1 tC n fn� o 5�0
Obst'n.:
Hall, Floor,Wall,Ceiling:
Hall Lighting:
Hall Windows:
HEATING ( Chimneys: Gk
Central L,Y�_ .0 N Equip. Repair I"100 d Pud 'vj
TYPE: all l�� Stacks, Flues,Vents:
PLUMBING: Supply Line:
❑ MS ❑ ST ❑ P Waste Line:
H.W.Tanks Safety and Vent(s)
ELECTRICAL Panels, Meters,Cir.: - ✓2a.6(.a
❑ 110 ❑ 220 Fusing,Grnd.:
AMP: Gen.Cond. Distrib. Box:
Gen. Basement Wiring:
DWELLING UNIT S ✓ '�
Ventil. L to Outlets Walls Ceils. Wind. Doors Floors Locks
Kitchen Z_
Bathroom
Pantry
Den
Living Room 4
Bedroom 1 ij;
Bedroom 2
Bedroom 3
Bedroom 4
Hot Water Facil. Sup.Ten.,Gas, il, lect.: °
Stacks, Flues,Vents,Safeties:
Kitchen Facilities Sink 1 D.-7 Ok
Stove C wa a--j U� r
Bathing,Toilet Facil. Vent., Plumb.,Sanit'n.:We t - XF i w--,t Pc r Ka., r;:- :
Wash Basin,Shower or Tub: 1-,;u, (Say6• d 50 4f wu,-u dowv►
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 PERJU Y
INSPECTOR E TITLE ,
DATE ID6/-U-yo 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 heaith, or safety and well-being of a person or persons occupying the premises. This listing is composed of those
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 11, 105 CMR 410.100 through 410.620 state minimum requirements of fitness for
human habitation, any other violation has the potential to fall within this category in any given specific situation but may not do so
in every case and therefore is not included in this listing. Failure to include shall in no way be construed as a determination that
other violations or conditions 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 such violation(s) pursuant to 105 CMR 410.830 through 410.833 nor shall failure to
include 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 CMR 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) Shutoff and/or failure to restore electricity or gas.
(D) Failure to provide the electrical facilities required by 105 CMR 410.250(B), 410.251(A), 410.253 and the lighting in com-
mon 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 disposal 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 any object,
including garbage or trash, which prevents egress in case of an emergency 105 CMR 410.450, 410.451 and 410.452.
(H) Failure to comply with the security requirements of 105 CMR 410.480(D).
(1) Failure to comply with any provisions of 105 CMR 410.600, 410.601 or 410.602 which results in any accumulation of gar-
bage, 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 leadbased paint on a dwelling or dwelling unit in violation of the Massachusetts Department of Public
Health Regulations for Lead Poisoning Prevention and Control, 105 CMR 460.000. (See M.G.L. c. 111 @@ 190,through 199.)
(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 safety.
(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 facilties 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 defect in asbestos material used as insulation or covering on a pipe, boiler or furnace which may result in the release
of asbestos dust or which may result in the release of powdered, crumbled or pulverized asbestos material in violation of 105
CMR 410.353.
(N) Failure to provide a smoke detector required by 105 CMR 410.482.
(0) 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 inoperable.
(2) Failure to provide a washbasin and shower or bathtub as required in 105 CMR 410.150(A)(2) and 410.150(A)(3)or 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, gasfitting, or electrical wiring standards that do not create an immediate hazard.
(4) 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.
(P) Any other violation of 105 CMR 410.000 not enumerated in 105 CMR 410.750(A)through (0)shall be deemed to be a con-
dition 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.
MRVP #
Assessors office (1st Floor) 7 y Q l
Assessors Map and Parcel # vG
Building Department (4th Floor) p p
Zoning � D
INSPECTION FEE
RE-INSPECTION FEE $15.00
Request For A Housing Inspection For Certification Under the
MA Rental Voucher Program
Your Name A4/rRj n_n ►'�
Affiliation (Circle One) Owner Real Estate Agent Tenant
Your Address L/ y F"7 m cs d:r� �a �.w�u,,� ll;pe, /1j,/
Telephone Number, (Day) 714 `/� / 337 7 (Night)
Address of Property Where Inspection is Requested
Unit/Apt.# 3l S k it XcC r?-,$ noI-r fl-, 4 P S ,
Name of Owner
Address
Mailing Address (if different)
Telephone Number (Day) (Night)
Will there be any children under the age of six (6) who ill
be occupying the rental unit? (circle one) Yes �N
Was the dwelling constructed prior to 1979? Yes No
------------------------------------------------------------
FOR OFFICE USE ONLY:
Certification
The dwelling, dwelling unit, or rooming unit located at
3 f It,,,(bt4 5 {►'.eelAA, o,-"v+.i✓ was inspected on
ry - 6 -Zrs.-*' b " grz, S , I Health
Inspector for the Town of Barnstable and was found to be in
compliance with the provisions contained within 105 CMR
410.00, State Sanitary Code II: Minimum Standards of Fitness
for Human Habitation. However, this certification does not
include a determination as to whether this unit contains any
lead paint because under 760 CMR 49.02 Massachusetts Rental
Voucher Program, a separ ea paint inspection must be
conducted.
Inspector's Signature
Date U — - 00'
inch E,a cel 288013 F�id Ow�@r \
,yj/' arc@[I� � 288013 ��p V n� 001911 � aretti;2 0000000 ��I � � A
DBYeI�I�Ot' / r/ otSl .61
�GSrr�Own BROWN, DAVID E&BARBARA T ,� as 109 /
4497 MIDDLE CHESHIRE
CANANDAIGUA NY 14424 w ct 00 0000 000 , <
January st r BROWN DAVID E&BARBARA T pee`d� YY 0000 earl of 2739/223
z r ='
l/atues� nd 000040700 Buildangs 000107900 Extra a res 0000000600 /
!. catlon 31 1 SMITH STREET o e x 1498 rfg, 0112
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