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1645 SANTUIT-NEWTOWN ROAD - Health
-�' -71 1645 S. ntuit-I`ewtown Road. , _ Cot-Lilt U24 - 041 -- 003 If 4-2 Il } 9R +I I I .. .. ,.. . wuut:mxc'a..wfe...^�..,�.......a:�.eiour�.:�r.lcafflM�- -�., - _. ,_..... .��-���....��u1':a: �4Ni�fi +�. �� .:..:.d -=���_:�.::s:yas.�lpersiF;a.�.�.:..:.,...::,�_�;_...��.b.v..�.�,�a�.�.... A:.�,-m �...r�.;., .e,. -.e�s64f1Yi'�,,.. .. ..,,�.� �..�.... ., n. � ,:;�: Number Fee 1302 THE COMMONWEALTH OF MASSACHUSETTS $5o.00 Town of Barnstable Board of Health This is to Certify that Capizzi Home Improvement ................................................................................................................................. 1645 Santuit-Newtown Road, Cotuit, MA .--------------------------------------------------------------------------------------------------------------------•--.....------......------------................... Is Hereby Granted a License For: Storing or Handling 26 - 110 gallons of Hazardous Materials. .................................................................................................................................................................... Restrictions: --------------------------------------------------------------------------_.......----.................................-----------................_....------_...... This license is granted in conformity with the Statutes and ordinances relating there to, and expires 06/30/2021 unless sooner suspended or revoked. -------------------------------------- JOHN NORMAN DONALD A.GUADAGNOLI,M.D. 07/01/2020 PAUL J.CANNIFF,D.M.D. THOMAS A.MCKEAN,R.S.,CHO Director of Public Health fir t+ g Town of Barnstable r• Inspectional Services BARNSTABLE PAk".Ta&.E•CEh'LF]V[LIF•fANR•FYAANIS Public Health Division "" • 3S(95-7201 = BAJW9rABM • Thomas McKean, Director f16 9. 200 Main Street, Hyannis,MA 02601 } I Office: 508-862-4644 Fax: 508=790-6304 110 APPLICATION FOR PERMIT TO STORE AND/OR UTILIZE '"" HAZARDOUS MATERIALS {;x IN ACCORDANCE WITH THE TOWN OF BARNSTABLE GENERAL ORDINANCE,CHAPTER 108, HAZARDOUS MATERIALS,ALL BUSINESSES THAT HANDLE OR STORE HAZARDOUS MATERIALS GREATER THAN HOUSEHOLD QUANTITIES ARE REQUIRED TO OBTAIN AN ANNUAL PERMIT(RUNS JULY 1 st-JUNE 30th). APPLICATION FEES ns: $ 50.00 ®/vim,CATEGORY 1 PERMIT 26— 110 Gallo V' CATEGORY 2 PERMIT 111 —499 Gallons: $125.00 ❑ (p CATEGORY 3 PERMIT 500 or more Gallons: $150.00 O *A late charge of$10 00 will be assessed if payment is not received by July 1st. 1. ASSESSOR'S MAP AND PARCEL NO. 2. IS THIS A PERMIT RENEWAL? YES_NO. IF YES,SKIP QUESTION 3. • 3. FOR ALL NEW PERMIT APPLICATIONS,INDICATE WHETHER BUSINESS HAS ZONINGBUILDING APPROVAL FOR HAZARDOUS MATERIALS STORAGE/USE OF GREATER THAN HOUSEHOLD QUANTITIES (25 GALLONS)? YES NO. 4. FULL NAME OF APPLICANT: 5. NAME OF ESTABLISHMENT: akc 7 7*, NOYn2 `�Mhr e n,2nV, 'r\c. 6. ADDRESS OF ESTABLISHMENT: q:S &nAA,�V - IWu) O n RA' CA�i Co6 7. MAILING ADDRESS(IF DIFFERENT FROM ABOVE: 50,Me 8. TELEPHONE NUMBER OF ESTABLISHMENT: 9. EMAIL ADDRESS: 6"1 C- cau raA. ►'��� —r 10. SOLEOWNER: y/ YES NO IF NO,NAME OF PARTNER: 11. FULL NAME,HOME ADDRESS,AND TELEPHONE#OF: CORPORATION NAME izli borne �Yy1Dra,�w�ey��� �n� PRESIDENT C�nnvnCLS C n i Z zi TREASURER CLERK 12. IF PREPARED BY OUTSIDE PARTY: NAME: TELEPHONE#: COMPANY ADDRESS EMAIL: SIGNATURE OF APPLICANT DATE Q:\Application Fonns\Haz Mat Appli Draft Jan2019.docx Number Fee 1302 THE COMMONWEALTH OF MASSACHUSETTS $so.00 Town of Barnstable Board of Health This is to Certify that Capizzi Home Improvement 1645 Santuit-Newtown Road, Cotuit, MA Is Hereby Granted a License For: Storing or Handling 26 - 110 gallons of Hazardous Materials. ---------------------------------------------------------------------------------------------------------------------- ----------------------------------- This license is granted in conformity with the Statutes and ordinances,relating there to,and and expires 06/30/2020 unless sooner suspended or revoked. PAUL J.CANNIFF,D.M.D,CHAIRMAN r DONALD A.GUADAGNOLI, M.D. 07/01/2019 JU_NICHI SAWAYANAGI THOMAS A.MCKEAN,R.S.,CHO Director of Public Health y Town of Barnstable Inspectional Services BARNSTABLE ' Op THE T[L- rnawsrnee.aar,:;^:i.:o-.m..rcazmr .y wvsc!u wius•as*rarue. Public Health Division =9_]014 BARNM.ABLE. * Thomas McKean, Director hU 9`bATE0 ;�h. 200 Main Street, Hyannis,MA 02601 r� Office: 508-862-4644 Fax: 508-790-6304 W APPLICATION FOR PERMIT TO STORE AND/OR UTILIZES HAZARDOUS MATERIALS IN ACCORDANCE WITH THE TOWN OF BARNSTABLE GENERAL ORDINANCE,CHAPTER 108, HAZARDOUS MATERIALS,ALL BUSINESSES THAT HANDLE OR STORE HAZARDOUS MATERIALS GREATER THAN HOUSEHOLD QUANTITIES ARE REQUIRED TO OBTAIN AN ANNUAL PERMIT(RUNS JULY 1 st-JUNE 3 Oth). APPLICATION FEES CATEGORY-1 PERMIT 26-.110 Gallons: -$ 50:00 V h K CATEGORY 2 PERMIT 111 —499 Gallons: $125.00 ❑ i-f 2— CATEGORY 3 PERMIT 500 or more Gallons: $150,00 ❑_ *A late charge of$10.00 will be assessed if payment is not received by July 1st. Ai I 1. ASSESSOR'S MAP AND PARCEL NO. 0�^V' 1 2. IS THIS A PERMIT RENEWAL? % YES,_NO. IF YES, SKIP QUESTION 3. 3. FOR ALL NEW PERMIT APPLICATIONS,INDICATE WHETHER BUSINESS HAS ZONING/BUILDING APPROVAL FOR HAZARDOUS MATERIALS STORAGE/USE OF • GREATER THAN HOUSEHOLD QUANTIT S (25 GALLONS)? YES NO. 4. FULL NAME OF APPLICANT: . 5. NAME OF ESTABLISHMENT: raTUA h V 6. ADDRESS OF ESTABLISHMENT: to q' lu Gil V'1'V 7. MAILING ADDRESS (IF DIFFERENT FROM ABOVE: 8. TELEPHONE NUMBER OF ESTABLISHMENT: 9. EMAIL ADDRESS: �( @ U%��L�O� ► (i' 10. SOLEOWNER: /YES NO IF NO,NAME OF PARTNER: 11. FULL NAME,HOME ADDRESS,AND TELEPHONE#OF: CORPORATIO NAME 4 PRESIDENT I 4b M TREASURER NIJ CLERK 12. IF PREPARED BY OUTSIDE PARTY: NAME: TELEPHONE#: • COMPANY ADDRESS EMAIL: SIGNATURE OF APPLICANT DATE _V Q:\Application Forms\Haz Mat App Revised 09-10-18.docx Number Fee 1302 THE COMMONWEALTH OF MASSACHUSETTS $50.00 .Town of Barnstable Board of Health This is to Certify that Capizzi Home Improvement 1645 Santuit-Newtown Road, Cotuit, MA Is Hereby Granted a License For: Storing or Handling 26 - 110 gallons of Hazardous Materials. This license is granted in conformity with the Statutes and ordinances relating there to,and and expires 06/30/2019 unless sooner suspended or revoked. ---------------------------------------- PAUL J.CANNIFF,D.M.D,CHAIRMAN DONALD A.GUADAGNOLI,M.D. 07/01/2018 JUNICHI SAWAYANAGI THOMAS A.MCKEAN, R.S.,CHO Director of Public Health 1 $S0�hK# g3 lowegu'Aatoryof B4rnsxable Services S� Richard V. Scali, Director t ° �, Public Health Division BARNSTABLE • Y BARNSfAEIE.f&rtfllY1LLF.Q)NT•HYMNIS snaxsrABLE. ' Thomas McKean, Director 1639-.o arm ea m,eE --200 Main Street,Hyannis,lVlA 02Ci01---- - ---- - -517�- --------— Office: 508-862-4644 Fax: 508-790-6304 APPLICATION FOR PERMIT TO STORE AND/OR UTILIZE HAZARDOUS MATERIALS IN ACCORDANCE WITH THE TOWN OF BARNSTABLE GENERAL ORDINANCE, CHAPTER 108, HAZARDOUS MATERIALS,ALL BUSINESSES THAT HANDLE OR STORE HAZARDOUS MATERIALS GREATER THAN HOUSEHOLD QUANTITIES ARE REQUIRED TO OBTAIN AN ANNUAL PERMIT(RUNS JULY 1 st—JUNE 3 Oth). APPLICATION FEES CATEGORY I PERMIT 26- 110 Gallons: $ 50.00 V's CATEGORY 2 PERMIT 111 —499 Gallons: $125.00 ❑ CATEGORY 3 PERMIT 500 or more Gallons: $150.00 ❑ *A late charge of$10.00 will be assessed if payment is not received by July 1st. 1. ASSESSOR'S MAP AND PARCEL NO. ®, ®� 2. IS THIS A PERMIT RENEWAL? V YES NO. IF YES, SKIP QUESTION 3. 3. FOR ALL NEW PERMIT APPLICATIONS,INDICATE WHETHER BUSINESS HAS ZONING/BUILDING APPROVAL FOR HAZARDOUS MATERIALS STORAGE/USE OF • GREATER THAN HOUSEHOLD QUANTITIES (25 GALLONS)? YES NO. 4. FULL NAME OF APPLICANT: 5. NAME OF ESTABLISHMENT: 6. ADDRESS OF ESTABLISHMENT: 7. MAILING ADDRESS(IF DIFFERENT FROM ABOVE: 0 ) 8. TELEPHONE NUMBER OF ESTABLISHMENT: � .- 9. EMAIL ADDRESS: 0)/y1 0 COCA d • y tie 10. SOLEOWNER:V YES NO IF NO,NAME OF PARTNER: 11. FULL NAME,HOME ADDRESS,AND ELEPHONE#OF: CORPORATIO NAME In ' e , PRESIDENT ® I TREASURE I 1 CLERK 12. IF PREPARED BY OUTSIDE PARTY: NAME: TELEPHONE#: • COMPANY ADDRESS EMAIL: SIGNATURE OF APPLICANT DATE 57M 11 Q:\Applica6on Forms\HAZMAT APP 2017 REVISED.doc ' E Number Fee 1302 THE =COMMONWEALTH OF MASSACHUSETTS $so.00 Town of Barnstable Board of Health This is to Certify that Capizzi Home Improvement 1645 Santuit-Newtown Road, Cotuit, MA Is Hereby Granted a License For: 'Storing or Handling 26 - 110 gallons of Hazardous Materials. ------------------------------------------------------------------ ------------------------------- -------------------------------------------------- This license is granted in conformity with the Statutes and ordinances relating there to,and and expires 06/30/2018 unless sooner suspended or revoked. -=------------------------------------ PAUL J.CANNIFF,D.M.D,CHAIRMAN DONALD A.GUADAGNOLI,M.D. 07/01/2017 JUNICHI SAWAYANAGI THOMAS A.MCKEAN,R.S.,CHO Director of Public Health fif TRowr .of B2wnstable eg atory Services Richard V. Scali, Director A,. ,9�t T fum Public Health Division BARNSTABLE B RNSrAtlL-i OERVILE.COiUR•NY4n::15 4ow BARNSPABLB• Thomas McKean, Director . 16'9-"201; en 639. s`0� 200 Main Street, Hyannis,MA 02601 Office: 508-862-4644 /� o aO! Fax: 508-790-6304 w1 �1 APPLICATION FOR PERMIT TO STORE AND/OR UTILIZE HAZARDOUS MATERIALS , IN ACCORDANCE WITH THE TOWN OF BARNSTABLE GENERAL ORDINANCE, CHAPTER 108, C HAZARDOUS MATERIALS,ALL BUSINESSES THAT HANDLE OR STORE HAZARDOUS MATERIALS GREATER THAN HOUSEHOLD QUANTITIES ARE REQUIRED TO OBTAIN AN ANNUAL PERMIT(RUNS JULY 1st-JUNE 30th). APPLICATION FEES CATEGORY 1 PERMIT' 26- 110 Gallons: $ SQO.OT' ' CATEGORY 2 PERMIT 111 -499 Gallons: $125.00 El CATEGORY 3 PERMIT 500 br more Gallons: $150.00 ❑ *A late charge of$10.00 will be assessed if payment is not received by July 1st. 1. ASSESSOR'S MAP AND PARCEL.NO. iL')0j L4 I.i 2. IS THIS A PERMIT RENEWAL? V YES NO. IF YES,SKIP QUESTION 3. 3. FOR ALL NEW PERMIT APPLICATIONS,INDICATE WHETHER BUSINESS HAS • ZONING/BUILDING APPROVAL FOR HAZARDOUS MATERIALS STORAGE/USE OF ,. GREATER THAN HOUSEHOLD QUANTITIES (25 GALLONS)?- YES NO. 4. FULL NAME OF APPLICANT: 1 5. NAME OF ESTABLISHMENT: �n p i zzi 16me-. ! 1m pr-n v YY),, I2 6. ADDRESS OF ESTABLISHMENT: �`�o _��-(�,` nQ llm VC4 op a� 7. MAILING ADDRESS (IF DIFFERENT FROM ABOVE: 8. TELEPHONE NUMBER OF ESTABLISHMENT: 9. EMAIL ADDRESS: CI)-I (3C _UP_ x • 1rl e t 10. SOLEOWNER: ✓ YES NO IF NO,NAME OF PARTNER: 11. FULL NAME,HOME ADDRESS,'AND TELEPHO #OF: CORPORATION NAME >n ipnoL _ hn a.- � h C� PRESIDENT�X)o _S C! 1 ZZI TREASURER -TbL Y 0 j 2)7 CLERK 12. IF PREPARED BY OUTSIDE PARTY: NAME: TELEPHONE#: . COMPANY ADDRESS EMAIL: SIGNATURE OF APPLICANT DATE QAApplication Fonns\IAZMAT APP 2017 REVISED.docx Number fee 1302 THE COMMONWEALTH OF MASSACHUSETTS $50.00 Town of Barnstable Board of Health This is to Certify that Capizzi Home improvement 1645 Santuit-Newtown Road, Cotuit, MA, Ns- Is Hereby Granted a License for: Storing or Handling 26 - 100 gallons of Hazardous Malerials.` L This license is granted in conformity,with the Statutes and ordinances relating there to, and and expires 06/30/2017 unless sooner suspended or revoked. WAYNE MILLER,M.D.,CHAIRMAN PAUL J.CANNIFF,D.M.D. 07/01/2016 JUNICHI SAWAYANAGI THOMAS A.MCKEAN,R.S.,CHO Director of Public Health .- ba � Town of Barnstable B Regulatory Services ti Richard V. Scali, Director BARNSTABLE `" MAS&'� ` Public Health Division w 1639 `0� osAB 'e Fx`sna Thomas McKean, Director 1639�4 200 Main Street, Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 l/ APPLICATION FOR PERMIT TO STORE AND/OR UTILIZE w HAZARDOUS MATERIALS IN ACCORDANCE WITH THE TOWN OF BARNSTABLE GENERAL ORDINANCE,CHAPTER 108, HAZARDOUS MATERIALS,ALL BUSINESSES THAT HANDLE OR STORE HAZARDOUS MATERIALS GREATER THAN HOUSEHOLD QUANTITIES ARE REQUIRED TO OBTAIN AN ANNUAL PERMIT(RUNS JULY 1st—JUNE 30th). APPLICATION FEES CATEGORY 1 PERMIT 26— 110 Gallons: $ 50.00 CATEGORY 2 PERMIT 111 —499 Gallons: $125.00 '❑ CATEGORY 3 PERMIT 500 or more Gallons: $15400 ❑ • A late charge of$10.00 will be assessed if payment..is not received by July 1st. ASSESSORS MAP AND PARCEL NO: q l OD 'DATE FULL NAME OF APPLICANT:',, OM AC to p1.LLi NAME OF ESTABLISHMENT: 64 eji4i de rn -rjw e verb,P� ,r y t ADDRESS OF ESTABLISHMENT: 1��� V e&-,&w i A',# 6 B-fvrt MAILING ADDRESS(IF DIFFERENT): A1/4 TELEPHONE NUMBER OF ESTABLISHMENT: EMAIL ADDRESS: C 4 Z C (A�e (a b . jV e__t SOLE OWNER: V YES . NO IF NO,NAME OF PARTNER: FULL NAME,HOME ADDU SS,ANT)TELEPHONE# OF: CORPORATION NAME (:,!gip/ZZi__.L.J�F��_ - r_f�e���� �OV PRESIDENT TREASURER ; T CLERK IF PREPARED BY OUTSIDE PARTY: Cie SIGNATURE OF ANT Name: Company Address Telephone#: Email: Q:\Application Forms\HAZZAPP Revl6.docx Page 1 of 2 114 T° Town of Barnstable Office:508-862-4644 Public Health Division Fax:508-790-6304 BARMARgB .� 200 Main Street• Hyannis, MA 02601 �p t639. M p�0 TOXIC AND HAZARDOUS MATERIALS INSPECTION REPORT rfD P'� Business Name: ® Date: a Location/Mailing Address: Contact Name/Phone: P� — Jv1S �t11S' �q IS! �TtlM ,p Inventory Total Amount: �2s CSDS: License#: Tier II : IO Labeling: Spill Plan: U cl�,4 Oil/Water Separator:_ Floor Drains: Emergency Numbers: v Storage Areas/Tanks: �R S GrQ� in Emergency/Containment Equipment: MCI Waste Generator ID: Waste Product: �n Date&Amount of Last Shipment/Frequency: rl e e Licensed Waste Hauler&Destination: �acl$Pit� Other Waste Disposal Methods: LIST OF TOXIC AND HAZARDOUS MATERIALS NOTE: Under the provisions of Ch. 111, Section 31, of the General Laws of MA, hazardous material use, storage and disposal of 111 gallons or more requires a license from the Public Health Division. Antifreeze Dry cleaning fluids Automatic transmission fluid Other cleaning solvents&spot removers Engine and radiator flushes Bug and tar removers Hydraulic fluid (including brake fluid) Windshield wash Motor oils Miscellaneous Corrosives Gasoline,jet fuel, aviation gas Cesspool cleaners Diesel fuel, kerosene, #2 heating oil Disinfectants Miscellaneous petroleum products: Road salts grease, lubricants, gear oil Refrigerants Degreasers for engines&garages Pesticides: �Caulk/Grout insecticides, herbicides, rodenticides Battery acid (electrolyte)/batteries Photochemicals(Fixers) Rustproofers Photochemicals(Developer) Car wash detergents Printing ink Car waxes and polishes Wood preservatives (creosote) Asphalt&roofing tar Swimming pool chlorine Vll aints, varnishes, stains, dyes Lye or caustic soda Lacquer thinners Miscellaneous Combustible Paint&varnish removers, deglossers Leather dyes Miscellaneous Flammables Fertilizers Floor&furniture strippers PCB's Metal polishes. Other chlorinated hydrocarbons Laundry soil &stain removers (including carbon tetrachloride) (including bleach) Any other products with "poison labels" (including chloroform, formaldehyde, hydrochloric acid, other acids) VIOLATIONS: ORDERS: INFORMATION/RECOMMENDATIONS: IN-1 ,.S V �2 efl�rdCnU4 �W,b Ian Inspector: Facility Representative: WHITE COPY- HEALTH DEPARTMENT/CANARY COPY- BUSINESS TMErokti Town of Barnstable Office:508-862-4644 Public Health Division Fax:508-790-6304 Y BARMACq .$ 200 Main Street• Hyannis, MA 02601 �p 2639.p�0 'FDMP+ TOXIC AND HAZARDOUS MATERIALS INSPECTION REPORT il'22�1 F, Business Name: C"X0 t-.-a- , a&Vt&-?— C'o-, ne -144r Date: Location/Mailing Address: Ivl`I e off, Contact Name/Phone: kejk 06 Invento Total mount: ^' ! SDS: o + LA�t,4° 6D6 License#-:-115D Tier II : 0 Labeling: ` Spill Plan: Oil/Water Separator: Floor Drains: o Imergency Numbers: ` Storage Areas/Tanks: 40M ��� W 'S pieO l000k&JrS Emer enc /Containme t E ui nt: ate. -cA, Waste Generator ID: 0 Waste Product: Date&Amount of Last Shipment/Frequency: Licensed Waste Hauler&Destination: Other Waste Disposal Methods: LIST OF TOXIC AND HAZARDOUS MATERIALS NOTE: Under the provisions of Ch. 111, Section 31, of the General Laws of MA, hazardous material use, storage and disposal of 111 gallons or more requires a license from the Public Health Division. Antifreeze Dry cleaning fluids Automatic transmission fluid Other cleaning solvents&spot removers Engine and radiator.flushes Bug and tar removers Hydraulic fluid (including brake fluid) Windshield wash Motor oils Miscellaneous Corrosives l Gasoline,jet fuel, aviation gas Cesspool cleaners Diesel fuel, kerosene, #2 heating oil Disinfectants Miscellaneous petroleum products: Road salts grease, lubricants, gear oil Refrigerants , Degreasers for engines&garages b�,<� Pesticides: I +3 sr-A T Caulk/Grout ad(,V-,L-S,veg N c°° insecticides, herbicides, ro enticides Battery acid(electrolyte)/batteriest'�� Photochemicals(Fixers) Rustproofers Photochemicals(Developer) Car wash detergents Printing ink Car waxes and polishes eetk b Wood preservatives(creosote) Asphalt&roofing tar °n Swimming pool chlorine Paints, varnishes, stains, dyes Lye or caustic soda Lacquer thinners Miscellaneous Combustible Paint&varnish removers, deglossers Leather dyes Miscellaneous Flammables t -�'V�Sa1\''1 Fertilizers Floor&furniture strippers �w PCB's Metal polishes Other chlorinated hydrocarbons Laundry soil &stain removers (including carbon tetrachloride) (including bleach) Any other products with "poison labels" (including chloroform, formaldehyde, hydrochloric acid, other acids) VIOLATIONS: ORDERS: INFORMATION/RECOMMENDATIONS: U4,c ,) vJ � roves oo-t s p c V-\- C $ 1 CPS�� GQ. . Insp ctor: . �-•av�.��.� �.¢. b�.,� � ,n,a�o�0.35 `M•�.,�,C�w�5 ���--e,�n,� �5 l �44'Aiv 7 5 , ?Oc� Facilityresentative: �"d WHIT �l\ p 901 PY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS TOWN OF BARNSTABLE Date: q ► S ► l► TOXIC AND HAZARDOUS MATERIALS t�� S N FORM NAME OF BUSINESS: CA p���; o,MtJltb�e.�ncutiC BUSINESS LOCATION: �b�15' SGlln�v --1J��knw� , Co��.k INVENTORY MAILING ADDRESS: TOTAL AMOUNT: TELEPHONE NUMBER: 50A - l5-1U CONTACT PERSON: ,�, evvl EMERGENCY CONTACT TEL PHONE N MBER: MSDS ON SITE? TYPE OF BUSINESS: �nwu.� �wHAco��.�n�-c,•�C 2S INFORMATION / RECOMMENDATIONS: Fire District: Waste Transportation: Last shipment of hazardous waste: Name of Hauler: Destination: Waste Product: Licensed? Yes No NOTE: Under the provisions of Ch. 111, Section 31, of the General Laws of MA, hazardous material use, storage and disposal of 111 gallons or more a month requires a license from the Public Health Division. LIST OF TOXIC AND HAZARDOUS MATERIALS The Board of Health and the Public Health Division have determined that the following products exhibit toxic or hazardous characteristics and must be registered regardless of volume. Observed / Maximum Observed / Maximum Antifreeze (for gasoline or coolant systems) Miscellaneous Corrosive ❑ NEW ❑ USED Cesspool cleaners Automatic transmission fluid Disinfectants Engine and radiator flushes Road salts (Halite) Hydraulic fluid (including brake fluid) Refrigerants Motor Oils Pesticides ❑ NEW ❑ USED (insecticides, herbicides, rodenticides) Gasoline, Jet fuel,Aviation gas Photochemicals (Fixers) Diesel Fuel, kerosene, #2 heating oil ❑ NEW ❑ USED Miscellaneous petroleum products: grease, Photochemicals (Developer) lubricants, gear oil ❑ NEW ❑ USED Degreasers for engines and metal Printing ink Degreasers for driveways &garages Wood preservatives (creosote) Caulk/Grout Swimming pool chlorine Battery acid (electrolyte)/Batteries Lye or caustic soda Rustproofers Miscellaneous Combustible Car wash detergents Leather dyes Car waxes and polishes Fertilizers Asphalt& roofing tar PCB's Paints, varnishes, stains, dyes Other chlorinated hydrocarbons, Lacquer thinners (including carbon tetrachloride) ❑ NEW ❑ USED Any other products with "poison" labels (including chloroform, formaldehyde, Paint&varnish removers, deglossers hydrochloric acid, other acids) Miscellaneous..Flammables Other products not listed which you feel Floor&furniture strippers may be toxic or hazardous (please list): Metal polishes Laundry soil &stain removers (including bleach) Spot removers &cleaning fluids (dry cleaners) Other cleaning solvents Bug and tar removers Windshield wash WHITE COPY-HEALTH DEPARTMENT I CANARY COPY-BUSINESS Applicant's Signature Staff's Initials Town of Barnstable �tMME►w�ti Regulatory Services Richard V. Scali, DirectorA At " Public Health Division BARNSTABLE 659. •� enrsnS ne F•4 rzav E•mrvrt•mawx s ♦ aearoarws.osrea:ue•wrren.xsme �fO1AA� Thomas McKean, Director 1639-2014 SS�g 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 APPLICATION FOR PERMIT TO STORE AND/OR UTILIZE HAZARDOUS MATERIALS IN ACCORDANCE WITH THE TOWN OF BARNSTABLE GENERAL ORDINANCE, CHAPTER 108, HAZARDOUS MATERIALS,ALL BUSINESSES THAT HANDLE OR STORE HAZARDOUS MATERIALS GREATER THAN HOUSEHOLD QUANTITIES ARE REQUIRED TO OBTAIN AN ANNUAL PERMIT(RUNS JULY lst—JUNE 30th). APPLICATION FEES CATEGORY I'PERMIT 26— 110 Gallons: $ 50.00 ❑ CATEGORY 2 PERMIT 111 —499 Gallons: . $125.00 ❑ CATEGORY 3 PERMIT 500 or more Gallons: $150.00 ❑ A late charge of$10.00 will be assessed if payment is not received by 1st. ASSESSORS MAP AND PARCEL NO. DATE , FULL NAME OF APPLICANT: NAME OF ESTABLISHMENT: _ ADDRESS OF ESTABLISHMENT: MAILING ADDRESS(IF DIFFERENT): TELEPHONE NUMBER OF ESTABLISHMENT: EMAIL ADDRESS: SOLE OWNER: YES NO IF NO,NAME OF PARTNER: FULL NAME,HOME ADDRESS,AND TELEPHONE#OF: ti CORPORATION NAME PRESIDENT TREASURER CLERK - - IF PREPARED BY OUTSIDE PARTY: SIGNATURE OF APPLICANT Name: Company Address Telephone #: Email: Q:\Application Fonns\HAZZAPP RevM.docz Pagel of 2 - r SPILL CONTINGENCY PLAN Emergency Coordinator, Name: Address: Daytime Phone: Evening Phone: i . Fire Department: l Barnstable Public Health Division: 508-862-4644 DEP 24 Hour Spill Hot Line: 888-304-1133 Waste Hauler: Name: Phone: Building diagram indicating hazardous material/waste storage area, location of absorbent scavenger materials, fire extinguishers, fire alarms (if present), and evacuation route (if applicable). Actions to be taken to control-a spill or release, and preventing it. from reaching a catch basin, sewer system or the ground. SPILL CONTINGENCY PLAN Emergency Coordinator, Name: CA e>ZZi S�Nro� Address: /(o `t 5 N-tug-tvL0jV 73r '�a�y9=�i H4 Daytime Phone: Evening Phone: Fire Department: Barnstable Public Health Division: 508-862-4644 DEP 24 Hour Spill Hot Line: 888-304-1133 Waste Hauler: Name: AZ Phone: , t Building diagram indicating hazardous material/waste storage area, location of absorbent scavenger materials, fire extinguishers, fire alarms (if present), and evacuation route (if applicable). � � J�� S 4-Ovie 6 AveA- ' b-e.h&4 .9-T,ecL Femtz it -e✓ 51 he �1A� A Np laC�eEC. i'w s�o/1�1 f� Actions to be taken to control a spill or release, and preventing it from' reaching a catch basin, sewer system or the ground. °V - • �/p/cerP,4 �p eo y/z 11ri"16 1666 Santuit-Newtown Rd-Goode Maps 1666 Santuit-Newtown Rd 40 Now le 0 Image capture:Jul 2014 02016 Google Barnstable,Massachusetts Street View-Jul 2014 1�645 Sontuit-Newtc `Road OLIVER Page 1 of 1 , DIM-r OLIVER:MassGIS's Online Mapping Tool OLIVER Updates / ntMo°ttrE ie INS P.OAD 8ANIU190WTROADOWN 1{16_� ,.. � lAIflURO�tNlN I iM! gAMiJT_off OWN 7,86 MN1�1T1a�4�n� MrsWT M (9ri http://maps.massgis.state.ma.us/map_ol/oliver.php 11/30/2016 k 20239 Pg 326 #62747 BLDG l "00000i OE oR`�WpY SO E� BLDG 2 Z z ASSESSORS MAP 24, ASSESSORS MAP 24, Z PARCEL 41--2 Q PARCEL 41-3 (� BARN lLA EXHIBIT SHOWING DRIVEWAY � �0 K LOCATION FOR EASEMENT �088& IN BARNSTABL& MA. $ PREPARED FOR ?e mOMAS CAPIzzi EAS OUND LAND SURVEWNG, INC P.O. SOX 442, FORESTDAL& MA TEL. : 508 477-4511 PROJECT- E00403 DWG: MAS7ER.DWG BARNSTABLE REGISTRY OF DEEDS S M E:A KEEPING YOU ORGANIZED No.90 2-153L MMEINUSA GET ORGANIC AT SMEAD.COM TOWN OF BARNSTABLE BOARD OF HEALTH Approved: � Z164 NiLD Cert: - -� ARTICLE II: MINIMUM STANDARDS FOR HUMAN HABITATION Date 3 I Z I b Time: In .DO Out S-N Owner ACCoL2tgT . LLC.- Tenant k iSTg-.4 eV..- 1 Z`�. �z Address c>aor ,t. Address Li(�o 5"t A-r'u`it - N EWToWN Rf1 C_a-tom NIA Compliance Remarks or Regulation# Yes NO Recommendations 2. Kitchen Facilities ,/ �'�-CLKEt S 3. Bathroom Facilities 4. Water Supply ✓ 5. Hot Water Facilities ✓ ' 2-06 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 p 6 e M 14. Insects and Rodents F.°I L I tj Zq.3 15. Garbage and Rubbish Storage and Disposal P , N pr 16. Sewage Disposal i A 17. Temporary Housing A/h- 18. Driveway Width 19. Number of Tenants Observed PART II f 37. Placarding of Condemned Dwelling; d N -T6 Removal of Occupants; Demolition Number of Bedrooms 2� SK' Number of Vehicles Allowed (max) 2 Number of Persons Allowed ax) Z-- Person(s) Interviewed ��ql��pector If Public Building such as Store or Hotel/Motel specify here 3 ; +AR.; 6.2009 9:15AM BARNSTABLE BOARD OF HEALTH NO.237 -P.1i1 Date To Whom It May'Concern: I, a luntarily grant permission to the Town (occupants name) of B stable Board of Health(Agent or Health Inspector) to inspect my dwelling unit I ated at (� in.accordance (House#, [Apt Unit#if applicable],street,village) with the Town of Bamstable Code(Ch ters 59 and 170) and the State Sanitary Code (105 CMR 410,000) ou I hereby authorize and name ate f inspection) to be my tenant representative for the (Occupant representative purpose of this inspection, �J2�1 adult person (Occupant representative) designated and duly authorized to act on my behalf and will be accompanying the Town of Barnstable Board of Health for the inspection, granting access to any and all locations (including bedrooms, bathrooms;closets, etc,,) allowing the use of photographs and answering questions. This authorization is only valid for the inspection date specified above, and must be renewed for any future inspection(s.) Ink 1 ' Occupants,Signature 1 Date S4 . Occupants Representative'Stgnature 1 Date Q:tiRental OrdinaacavrISPe000 permission-Moe - - TOWN OF BARNSTABLE Approved:-41t MLD Cert: G BOARD OF HEALTH ,_._=_ ARTICLE II: MINIMUM STANDARDS FOR HUMAN HABITATION Date 3 ( 2 , O Gl Time: In Out 11 , 10 ANt Owner A L�--c_ Tenant L u C i \A t L l— Address -I-e—Address I H Co5 Compliance Remarks or Regulation# Yes NO Recommendations 2. Kitchen Facilities SNA2£Ip 3. Bathroom Facilities 4. Water Supply 5. Hot Water Facilities 1 6. Heating Facilities 7. Lighting and Electrical Facilities 8. Ventilation 9. Installation and Maintenance of Facilities 10. Curtailment of Service i s O� 11. Space and Use f 12. Exits O ' viGiN� 0V/ 4 ICOit �cc-off- STeIXS 13. Installation and Maintenance of Structural 7 �` �"` Elements F-L-o o e- to v' 14. Insects and Rodents 17— 5"1% 15. Garbage and Rubbish Storage and Disposal 1 V4 A 16. Sewage Disposal 17. Temporary Housing N A 18. Driveway Width f 19. Number of Tenants Observed d PART II 37. Placarding of Condemned Dwelling; Removal of Occupants; Demolition Number of Bedrooms �`S Number of Vehicles Allowed (max) 2 Number of Persons Allo 2 jhPerson(s) Interviewed "ectorz If Public Building such as Store or Hotel/Motel specify here -jjAR. 5.2009 9:22AM BARNSTABLE BOARD OF HEALTH NO.225 t ' P.1i1 Date r. To Whoin It May'Concem: n CL�== LI ,voluntarily grant perMission to the Town (Occupants name) of H rn.stable'Board of Health(Agent or Wealth Inspector)to Inspect my dwelling unit i locatedatUqq CLLU&A-a ' in accordance ( ouse#, [Apt\Unit#if applicable],streets village) with the Town ofBamstable Code(Chapters 59 and 170) and the State Sanitary Code (105 CMR.410.000) ou ' a , I hereby authorize and name cc ate a iuspeation) to be my tenant represmi tative for the (Occupant representative) purpose of this inspection. eA2--•f1 is an adult person (Oacupaxit representativa) designated and duly authorized to act on my behalf and will be accompanying the Town of Barnstable Board of Health for the inspection, granting access to any and all locations (including bedrooms,bathrooms,closets, etc.,)allowing the use of photographs azd answering questions. This authorization is only valid for the inspection date specified above, and must be renewed for any future inspectioa(s) Occupants.S*na 1• Date p� Occupants Repr'esentative'Signature 1 Date Q:UkotalOndina Vrispectionpumisston,2.doe r, TOWN OF BARNSTABLE Approved: 11P BOARD OF HEALTH MLD Cert: ��Q ARTICLE II:MINIMUM STANDARDS FOR HUMAN HABITATION Date R-_ - 2.0 o Time: in 1 G,' $0 Out J/,'a 0 Owner L L-c- Tenant Vkw-i- �'1� I,C o.N-Li C Address 210 Address �v S` �,®�-10VI �J 5- w eo T u t 7 Compliance Remarks or Regulation# Yes NO Recommendations 2. Kitchen Facilities 3. Bathroom Facilities 4. Water Supply 5. Hot Water Facilities 6. Heating Facilities 4LL \f IUD 0,-1 i a a,S 7. Lighting and Electrical Facilities €�-v 0"'1 2 X0 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 17. Temporary Housing 18. Driveway Width 19. Number of Tenants Observed PART II 37. Placarding of Condemned Dwelling; Removal of Occupants; Demolition Number of Bedrooms S Number of Vehicles Allowed (max) y Number of Persons Allo d (max) Person(s) Interview e Inspector Mac_ C��a G3oT If Public Building such as Store or Hotel/Motel specify here TOWN OF BARNSTABLE Approved: ®�_ BOARD OF HEALTH MLD Cent: ARTICLE II: MINIMUM STANDARDS FOR HUMAN HABITATION Date 3 I I2�ag Time: In I DO Out 11: Owner N�/I:,S'C M�t� I A GLo U N-(, LLC- Tenant CA Address "<;- Ac�dress�y ��� JA N-CuIT- v wTowti� CnTu T N`A Compliance Remarks or Regulation# Yes NO Recommendations 2. Kitchen Facilities 3. Bathroom Facilities 4. Water Supply 5. Hot Water Facilities 2 p© r 6. Heating Facilities �AS 7. Lighting and Electrical Facilities 8. Ventilation 9. Installation and Maintenance of Facilities 10. Curtailment of Service 11. Space and Use 12. Exits 'r 6 13. Installation and Maintenance of Structural Elements 14. Insects and Rodents 15. Garbage and Rubbish Storage and Disposal 16. Sewage Disposal t/ I \&A—f C 17. Temporary Housing 18. Driveway Width 19. Number of Tenants Observed ('J PART II 37. Placarding of Condemned Dwelling; Removal of Occupants; Demolition Number of Bedrooms I /5S s Number of Vehicles Allowed (max) 2 Number of Persons Allowed a Z $*�Person(s) Interviewed4b Inspector �.S If Public Building such as Store or Hotel/Motel specify here � e FORM 30 C&w HOBBS&WARREN TM THE COMMONWEALTH OF MASSACHUSETTS BOARD OF TH T /TOWN W DEPARTME T / ADDRESS GSM 5 9�`0 6 � � TELEPHONE Address #��Occupant_ Floor Apartment No. No. of Occupants3 No.of Habitable Rooms��No.Sleeping Rooms No.dwelling or rooming units - ,o.Stories Name and address of owner— jus Remarks Reg. Vio. YARD Out Id s.: Fences: Garbage and Rubbish Containers: Drainage Infestation Rats or other: STRUCTURE EXT. Steps,Stairs, Porches: Dual Egress:and Obst'n.: h. ❑ B ❑ F ❑ M Doors,Windows: Roof Gutters, Drains: Walls: Foundation: Chimney: BASEMENT Gen.Sanitation: Dampness: vir Stairs: Li htin : STRUCTURE INT. Hall,Stairway: Obst'n.: Hall, Floor,Wall,Ceiling: Hall Lighting: Hall Windows: HEATING Chimneys: Central ❑ Y ❑ N E ui . 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 11220 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 Living Room Bedroom 1 " Bedroom 2 Bedroom 3 Bedroom 4 Hot Water Facil. Sup.Ten.,Gas, Oil, Elect.: 5ftk,s,FILiqs,o e ,Safeties.- Kitchen Facilities Sink ve Bathing,Toilet Facil. Vent., Plumb.,Sanit'n.: Wash Basin, Shower or Tub: Infestation Rats, Mice, Roaches or Other: Egress Dual and Obst'n: c- 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 INSPECTIO R PORT IS SIGNED AND CERTIFIED UNDER THE PAINS AND PENALTIES J RY." INSPECTOR TITLE 14411�_ A. J P DATE I �° TIME A.M. THE NEXT SCHEDULED REINSPECTION P.M. S. 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 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 CMR410.250(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. t (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. - r. ad 50 CJ --r,o 4.. Z 5� a I . I oFt rti Town of Barnstable Regulatory Services BMWSfABLE, 9 `""SS. i639• Thomas F. Geiler,Director ♦0 Public Health Division Thomas McKean, Director 200 Main Street, Hyannis, MA 02601 FACSIMILE TRANSMITTAL DATE: September 19,2007 NUMBER OF PAGES INCLUDING COVER: 5 TO: Tom Capizzi,Sr. FROM: Caitie Barrett PHONE: PHONE: (508)862-4644 FAX PHONE: 508-428-1547 FAX PHONE: (508)790-6304 cc: ❑ Urgent _X For Your Review ❑ Please Reply ❑ Reply ASAP NOTES/COMMENTS: Good Morning Tom, Following are the forms we spoke of. If you would, please let your tenants know the only time we take pictures is if there is mold or perhaps some wiring problem, it will never be of any of their belongings, only structural elements that may need documentation to show condition. Also following is a list of what we inspect for (may seem like a lot but goes very quickly). Please have ready for Tim O'Connell at the time of inspection. Thank you for your time and attention to this matter. eBarr(tt Health Division Rental Program Coordinator #508-862-4072 Direct Line JAFax Covendoc Date voluntarily grant permission to the Town (Occupants name) of Barnstable Board of Health(Agent or Health Inspector)to inspect my dwelling unit located at ��PA+� �� �� in accordance (House#, [Apt\Unit#if applicable],street,village) with the Town of Barnstable Code (Chapters 59 and 170) and the State Sanitary Code (105 CMR 410.000) on bA t� a la ��Som. I hereby authorize and name (Date of inspection) to be my tenant representative for the (Occupant representative) purpose of this inspection. is an adult person (Occupant representative) designated and duly authorized to act on my behalf and will be accompanying the Town of Barnstable Board of Health for the inspection, granting access to any and all locations (including bedrooms, bathrooms, closets, etc.,) allowing the use of photographs and answering questions. This authorization is only valid for the inspection date specified above, and must be renewed for any future inspection(s.) Occupants Signature \ Date Occupants Representative Signature \ Date s Q:\Rental Ordinance\inspection permission 2.doc 1 Date voluntarily grant permission to the Town (Occupants name) of Barnstable Board of Health (Agent or Health Inspector) to inspect my dwelling unit located at in accordance (House#, [Apt\Unit#if applicable],street,village) with the Town of Barnstable Code (Chapters 59 and 170) and the State Sanitary Code (105 CMR 410.000) on 5 y I hereby authorize and name (Date of inspection) to be my tenant representative for the (Occupant representative) purpose of this inspection. is an adult person (Occupant representative) designated and duly authorized to act on my behalf and will be accompanying the Town of Barnstable Board of Health for the inspection, granting access to any and all locations (including bedrooms, bathrooms, closets, etc.,) allowing the use of photographs and answering questions. This authorization is only valid for the inspection date specified above, and must be renewed for any future inspection(s.) \ Occupants Signature \ Date Occupants Representative Signature \ Date Q:\Rental Ordinance\inspection permission 2.doc Date voluntarily grant permission to the Town (Occupants name) of Barnstable Board of Health (Agent or Health Inspector)to inspect my dwelling unit located at S"C'kk >%k-New ". in accordance (House#, [Apt\Unit#if applicable],street,village) with the Town of Barnstable Code (Chapters 59 and 170) and the State Sanitary Code (105 CMR 410.000) on O4pVjQ_�- q e I'.J�o-M. I hereby authorize and name (Date of inspection) T % to be my tenant representative for the (Occupant representative) purpose of this inspection. is an adult person (Occupant representative) designated and duly authorized to act on my behalf and will be accompanying the Town of Barnstable Board of Health for the inspection, granting access to any and all locations (including bedrooms, bathrooms, closets, etc.,) allowing the use of photographs and answering questions. This authorization is only valid for the inspection date specified above, and must be renewed for any future inspection(s.) Occupants Signature \ Date Occupants Representative Signature \ Date Q:\Rental Ordinance\inspection permission 2.doc Following are some of the things the health inspector will be looking for at the inspection.. . -Measuring bedrooms to determine how many occupants can occupy each room -Testing hot water temperature to be 'sure it is 110-130 degrees Fahrenheit -Checking to see that there are smoke detectors and carbon monoxide alarms on every habitable floor within ten feet of bedrooms -Checking to see any mold or signs of chronic dampness that could lead to mold -Structural elements in need of repair (i.e. holes in walls, broken windows, leaking roofs, missing cabinet doors, peeling or chipping paint, etc. . ) -Screens in place on windows & doors during season (in good condition) -Light covers & switch plates in place -No temporary wiring -GFCI outlets grounded properly (outlets in kitchen and bathroom, near water sources) -Any decks, porches, balconies etc. that are 30" in height are to have a 36" high guardrail and balusters that are no more then 4 1/2" apart. -Check to see if there is an infestation of insects or entry points for rodents. This is the basis of things I have seen in order letters. FAX PHONE:$08.429-1547 FAX PHONE: (508)790.6304 cc: M Urgent X For Your Re-Aew ® Please Reply ® Reply ASAP NOTES/COMMENTS: Good Morning Tom, in are the forms we spoke of. If you would lease let our tenants know the Following p y 9 p �' only time we take pictures is if there is mold or perhaps some wiring problem,it will, � eia,ver be of any of their belongings,only structural elements that may need documentation to show condition. Also following is a list of what we inspect for (may seem like a lot but goes very quickly). Please have ready for Tim O'Connell at the time of inspection. Thank you for your time and attention to this mutter. C41e Barreettt Health Division Rental Program Coordinator 0508-862-4072 Direct Live J:1Fax cover'd4P NOI193WHOO 3-IIWIS0UJ ON 07-3 63MSNIJ ON (6-3 ASKS (2-3 -IIad 3NI-1 JO dl 9NdH (Z-3 K&13 60i WOSJ3d ------------------------------------- S/S 'd NO ZVSZ86tr89ST6 xi ).d0w--: ; V96 --------------------------------------------------------------------------------------------------------- 30Jd i-inS36 (jno65) SS3aGQU N0I1d0 3G.OW 3-1I-1 Hi-11J3H d0 96UG9 3-19t11SNdd9 Ill ( Wd9V:8Z Z002'6T'd3S ) 1Wd36 i-ins36 N0IIH:JINf1WWO0 T 'd Thomas Capizzi, Sr 1645 Newtown Road Cotuit, MA 02635 Ph: 508-428-9518/F: 508-428-1547 Dear Tenants, T The Barnstable Health Division will be coming to inspect your rental unit on October 2, 2007 at 1:15Pm. If you are not available to be there you will need to appoint a representative to be there on your behalf. I am more than willing to do this for you, as I will be present at this inspection: There is a list provided from the.Health Division that states what they are looking to inspect. Please note that the inspector will need access to all locations of the unit, including closets. They will need to take photographs of any problem areas. I have been assured that they will not be taking pictures of any personal items. Any questions, please call me. Tom Sr. 5o8-274-4230 Date .QC v`�00 I, ZA, i-11- 3QCA(�g ,voluntarily grant permission to the Town (0 pants name) of Barnstable Board of Health(Agent or Health Inspector)to inspect my dwelling unit located at N6g5 MLW s^ in accordance (House#,(Apt\Unit#if applicable],street,village) with the Town of Barnstable Code (Chapters 59 and 170)and the State Sanitary Code (105 CMR 410.000) on I hereby authorize and name (Date of iuspecti,on) to be my tenant representative for the (Occuparitrepresentative) purpose of this inspection, is an adult person (Occupant representative) designated and duly authorized to act on my behalf and will be accompanying the Town of Barnstable Board of Health for the inspection, granting access to any and all locations (including bedrooms,bathrooms, closets, etc.,)allowing the use of photographs and answering questions. This authorization is only valid for the inspection date specified above, and must be renewed for any future inspection(s) Oc pants Signature 1 Date 1 Occupants Representative Signature 1 Date Q:IRental OrdinencelinspccdQu pzinlsWon 2.doc SSE'd b98'0W Hl-lU3H 30 GZIU09 3-19d1SW8U9 WdSt7:0ti Z8 0E'6T'd3S Following are some of the things the health inspector will be looking for at the inspection. , , -Measuring bedrooms to determine how many occupants can occupy each room -Testing hot water temperature to be sure it is 110-130 degrees Fahrenheit -Checking to see that there are smoke detectors and carbon monoxide alarms on every habitable floor within ten feet of bedrooms -Checking to see any, mold or signs of chronic dampness that could lead to mold -Structural. elementa in need of: repair (1.5, holes in walls,: broken windows, leaking roofs,_ missing cabinet doors, peeling or chipping paint, etc. .) . -Screens in place on windows & dooxs during season (in good_Condition) -Light covers & snitch plates in place -No temporary wiring -GPCI outlets grounded properly (outlets in kitchen and bathroom, near water sources) -Any decks, porches, balconies etc. that are 301, in height are to have a 36" high guardrail and balusters that are no more then 4 1/2" apart. -Check to see if there is an infestation of insects or entry points for rodents. This is the basis of things I have seen in order letters S/S d. b98 ON Hi-1133H 30 CINH09 379djtH�Jba Wd9b:0Z Z002'6Z'd3S Thomas Capizzi, Sr 1645 Newtown Road Cotuit, MA 02635 Ph: 508-428-9518/ F: 5o8-428-1547 Dear Tenants, The Barnstable Health Division will be coming to inspect your rental unit on October 2, 2007 at 1-:i5Pm. If you are not available to be.there you will need to appoint a representative to be there on your behalf. I am more than willing to do this for you, as I will be present at this inspection. There is a list provided from the Health Division that states what they are looking to inspect. Please note that the inspector will need access to all locations of the unit, including closets.They will need to take photographs of any problem areas. I have been assured that they will not be taking pictures of any personal items. Any questions, please call me. Tom Sr: 5o8-274-4230 Date 64k Dal I, , voluntaxily grant permission to the Town (Occupants name) of Barnstable Board of Health(Agent or Health Inspector)to inspect my dwelling unit located at 11 ey5a�, °,k• �) u�n 5�� �d is accordance (House#, [AptlUnit#if applicable],street,village) with the Town of Barnstable Code(Chapters 59 and 170) and the State unitary Code (105 CMR 410.000) on . I hereby authorize and name (Date of inspection) to ba my tenant representative for the ( c pant representative) purpose of this inspection. V V t is an adult person (OcMp= repY%TntRve) designated and duly authorized to act on my behalf and will be accompanying the Town of Barnstable Board of Health for the inspection, granting access to any and all locations (including bedrooms,bathrooms, closets, etc,,) allowing the use of photographs and answering questions. This authorization is only valid for the inspection date specified above, and must be renewed for any future inspection(s,) Occupant ignature 1 Date Occupants Representative Signature 1 Date Q:IRental Ordinancelinspeation pa=lssion 2,doc S/2'd t7ge'ON Hi-ld3H d0 GNU09 3-19d1SNdUg WdSV:OT Z002'6T'd3S r Following are some of the things the health inspector will be looking for at the inspection. , -Measuring bedrooms to determine. how many occupants can occupy each room -Testing hot water temperature to be sure it is 110-130 .degrees Fahrenheit -Checking to see that there are smoke detectors and carbon monoxide alarms on every habitable floor within ten feet of bedrooms Checking to see any mold or aigns'of chronic dampness that could lead to mold -structural elements in_ need.of. repair (i.e. holes in walls', broken windows, leaking roofs, missing cabinet doors, peeling or chipping paint, etc. .) -Screens in place on windows & doors during season (in good Condition) -Light covers & switch plates in place -Notemporary wiring -GVCI outlets grounded properly (outlets in kitchen and bathroom, near water sources) _ -Any decks, porches, 'balconies etc. that are 30" in height are to have a 3611 high guardrail and balusters that.are no more then 4 1/2" apart. -Check to see if there is an infestation of insects or entry points for rodents. This is the basis of things I have seen. in order. letters. S/.S'd b9e'ON Hi-lU3H 30 GdIJOH 339diSWdU9 Wa9b:0 Z z002 G T.'d3S } ^ << -12-2011 10:27 From:BARNST HEALTH 15087906304 To:915084200318 P.1/3 Date -- i „ j'o Whom It May Concern. 1'�SU - , vol itlt<<nly grant pC:rn7issiOn to tfle Tow i. (Occupants name) • of Barn.stahle'I ioard of Tkalth (A.gctit or Health In q)ector) to.ir)sl)ect Illy dwelling 11nit located at , iri accordari(x (Hon cll, t1 [�1pTJnItlJ ifapplicable],slrcct,village) with the'Town. of Barnstable Codf:(Chapters 59 and 170) ,arid the State Sanitzry C'.ucIc (10.5 CMR 410.O00) on ,_ 1 hereby AUtltoxiZe atzd bane (T etc o1 inspection) to'E)c my t-t:nant represc:Irtativef-ijz the (Occupant rcprr. •ntativc) purpose Of this i.Iispc;ctior). is an aritllt persoll (Occupant rcpresd native) designated find duly authorized tO act oil my beb.alf alzd will be act:0111paizying the Town of Ba►astable)3oarci of'Heaith fi)r fhe irtspec.tioti, gt;3.t)t]Ii aect ss to,, ;iIId all ►,tJe$II()riS (inchlding bedrooms, hatlu•oorl-ls, closets, etc,,) allowinf;tlic 11st o1 photographs and answerirlg que.stiob)s, TJjj,S all(horization is only valid for the inspection da.tc specified abowc;alld Irltist be renewed For any flitult In j�ectiuti.(s-) Uccup311i.; Siamtture 1 Date; _ 1 Occupants kcpl-esenlativc,Sif nt�itire 1 l)ate naRcmal Ord in:ItILCVII';peC-Grm lu.rmissioa 2.doc J . TOWN OF BARNSTABLE BOARD OF HEALTH ARTICLE II: MINIMUM STANDARDS FOR HUMAN HABITATION Date �� Time: in Out U' Owner enant Address °" Address Compliance Remarks or Regulation# Yes O Recommendations 2. Kitchen Facilities 3. Bathroom Facilities 4. 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 17. Temporary Housing ,(7 C) r C 18. Driveway Width l 19. Number of Tenants Observed PART II 37. Placarding of Condemned Dwelling; Removal of Occupants; Demolition? Number of Bedrooms ✓ Number of Vehicles Allowed ( ax) _v Number of Persons Allowed (max)_5 -_[: Person(s) Interviewed Inspector If Public Building such as Store or Hotel/Motel specify here � TOWN OF BARNSTABLE BOARD OF HEALTH ARTICLE II: MINIMUM STANDARDS FOR HUMAN HABITATION O Date Time: In Out Owner J�����/ `"" l LL "Tenant Address v Address ( 6 1 1 v 6 Compliance Remarks or Regulation# Yes LAO Recommendations 2. Kitchen Facilities 3. Bathroom Facilities 4. Water Supply 5. Hot Water Facilities 6. Heating Facilities WWI I 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 Y 17. Temporary Housing cpfV 18. Driveway Width 2 19. Number of Tenants Observed ✓ �2 L PART II 37. Placarding of Condemned Dwelling; Removal of Occupants; Demolition Number of Bedrooms Number of Vehicles /Allowed (max Number of Persons Allowed (max) �- 17 Person(s) Interviewed Inspector If Public Building such as Store or Hotel/Motel specify here r gonpOt, O� OF BARNSTABLE LOCATION SEWAGE # ' II,LAGE -1t En ASSESSOR'S MAP &LOTS ', INSTALLER'S NAME&PHONE NO.�d� m P i �, es SEPTIC TANK CAPACITY �k —ZO � � t LEACHING FACILr Y: (type) tZ�r"1. (size) NO.OF BEDROOMS. BUILDER OR O (Yllliuilc U PERMITDATE: COMPLIANCE DATE: 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 fee of.leaching facility) Feet Furnished by � >• ff f M -t A- �-77`�' �- ?S` �` �- 8 t, -7�- 71 rs k TOWN OF,BBARNSTABLE ,,LOCATION��.��� �" `et� SEWAGE #_ _ VILLAGE CclV�t` _ ASSESSOR'S MAP & LOT Q / t10 INSTALLER'S NAME & PHONE NO. SEPTIC TANK CAPACITY 000, C, LEACHING FACILITY:(type)_ (size) NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER BUILDER O OWNER 07�1, C01 0 2-1-1 DATE PERMIT ISSUED: DATE COZiPLIANCE ISSUED: VARIANCE GRANTED: Yes No 1 �' "�`� �� ,� . �`:' ����`� �� � �' � . � ��� - � �� J BUILDER TO CONFIRM ALL CONDITIONS AND DIMENSIONS ON 51TE y -,3 N E Note:These plans are for the sole purpose and ` M C use of Capizzi Home Improvement and are not n a E n to be distributed or used for construction other 8 s s than by Capizzi Home Improvement. a E a 'a in Ln j . N 5 , h o EX Ia. 0 13'-b 114" I %� 5TAIR f/ V r- 54, 11'_1�" 3' J 5' <-- -8 1/2"r i EXISTING W OATH Q BATHLU O PEDESTAL w ff SINK v PROPOSED ------ LL 71 f I- rvOFFICE-� EXI5TIN Q 0 EXISTING ILIA O CLOSET TO BE REMOVED N ---- r� 47 T C im RE GATE DOOR in -- E _ - 3 N EXISTING OFFICE { O Ln U z _ in - ------------------------- ------------------------------------------ STORAGE t31e-1: Revis EXISTING 12- 1 1-6 1-18- 1 6' EXI5TING OFFICE J 6 2-14-t1 3-6-11 a. Final: 1 -FIRST FLOOR PLAN scale: 1/4=1-0 s oll P M V J 1 w ,� o, .�` 7_ \ur IAl - 71 r, 08:11b SEEN 45- 6'' + - TOXIC AND HAZARDOUS MATERIALS REGISTRATION FORM NAME OF BUSINESS:.0 1 Mail To: BUSINESS LOCATION: e- v� f Board of Health Town of Barnstable MAILING ADDRESS: P.O. Box 534, TELEPHONE NUMBER:' 0�— � �.':S�f Hyannis, MA 02601 CONTACT PERSON: EMERGENCY CONTACT TELEPHONE NU BER: � f - Does your firm store any of the toxic or hazardous materials listed below, either for sale or for your own use, in quantities totallin , at any time, more than 50 gallons liquid volume or 25 pounds dry 9 wei ht? YES NO This form must be returned to the Board of Health regardless of a yes or no answer. Use the enclosed envelope for your convenience. If you answered YES above, please indicate if the materials are stored at a site other than your mailing address: ADDRESS: TELEPHONE: LIST OF TOXIC AND HAZARDOUS MATERIALS The Board of Health has determined that the following products exhibit toxic or hazardous character- istics and must be registered regardless of volume. Please estimate the quantity beside the product that you.store: Quantity/Case Quantity/Case Antifreeze (for gasoline or coolant systems) Drain cleaners Automatic transmission fluid Toilet cleaners `7 T Engine and radiator flushes Cesspool cleaners - — A��Hydraulic_fluid (including brake fluid_) Disinfectants ISJ Motor oils/waste oils Road Salt (Halite) 10 Gasoline, Jet fuel Refrigerants 64-L Diesel fuel, kerosene, #2 heating oil Pesticides (insecticides, herbicides, � Other petroleum products grease, lubricants e��rodenticides) Degreasers for engines and metal Photochemicals (fixers and developers) Degreasers for driveways & garages Printing ink Battery acid (electrolyte) I�W,Wood preservatives (creosote) Rustproofers Swimming pool chlorine Car wash detergents Lye or caustic soda Car waxes and polishes Jewelry cleaners Asphalt & roofing tar Leather dyes 6A'tPaints, varnishes, stains, dyes Fertilizers (if stored outdoors) *'Paint & lacquer thinners PCB's _ &O-Paint & varnish removers, deglossers Other chlorinated hydrocarbons, Paint brush cleaners (inc. carbon tetrachloride) Floor & furniture strippers Any other products with "Poison labels Metal polishes (including chloroform, formaldehyde, Laundry soil & stain removers hydrochloric acid, other acids) (including bleach) Other products not listed which you feel may Spot removers & cleaning fluids be toxic r haz rdous (please list): (dry cleaners O br Other cleaning solvents Bug and tar removers Household cleansers, oven cleaners White Copy Health Department/ Canary Copy-Business L l �J TOWN OF BARNSTABLE COMPLIANCE: CLASS: 1.Marine,Gas Stations,Repair BOARD OF HE TH satisfactory 2.Printers 3.Auto Body Shops ty.�. ;ash 0 unsatisfactory- 4.Manufacturers COMPANY (see"Orders") 5.Retail Stores ;�. 6.Fuel Suppliers ADDRESS Zd Ak Eta At eRz"Class: 7 7.Miscellaneous 42a-7-V1-W" QUANTITIES AND STORAGE (IN=indoors; OUT=outdoors) MAJOR MATERIALSUndergroundove Tanks IN OUT IN OUT IN OUT #&gallons Age Test Fuels: Gasoline,Jet Fuel (A) Diesel, Kerosene, #2 (B) Heavy Oils: waste motor oil (C) new motor oil (C) transmission/hydraulic Synthetic Organics: degreasers Miscellaneous: Z / r 'e,- .lei'P, -r , a Ali, DISPOSAL/RECLAMATION REMARKS: 1. Sanitary Sewage 2.Water Supply O Town Sewer u4 (,Public On-site "0Private 3. Indoor Floor Drains YES-NO ko' O Holding tank: MDC O Catch basin/Dry well O On-site system 4. Outdoor Surface drains:YES-NO ORDERS: O Holding tank:MDC O Catch basin/Dry well s O On-site system J� " t� r 5.Waste Transporter Name of Hauler Destination YES NO 1. 2. 41000 .19 Pe n (s) Interviewed Inspector �. Date 5 `From Design to Completion. ROOM ADDITION INSULATION •Dormers •Existing Home Specialists •Second Stories •Blown-In Insulation •Family Rooms •State Certified and Approved •Sun Spaces •Porch Enclosures •Garages ALUMINUM REMODELING •Custom Trim •Seamless Gutters •Kitchens •Triple Glazed Replacement •Baths Windows •Interiors •Storm Windows •Exteriors •Doors SIDING •vinyl ROOFING •Cedar Shingles and Clapboard •Aluminum -ALL TYPES Free Estimates Builder Lic. N0.007454 I C, PIz Home Improvement "Quality" ,6.Oew&,ve,f 9�e�eirt nd�! THOMAS CAPIZZI 428-9518 1-800-262-5060 1645 Newtown Road Cotuit,MA 02635 TOWN OF BARNSTABLE COMPLIANCE: CLASS: 1.Marine,Gas Stations,Repair satisfactory 2.Printers BOARD OF HEALTH 3.Auto Body Shops O unsatisfactory- 4.Manufacturers COMPANY t Z Z (see"Orders") 5.Retail Stores 6.Fuel Suppliers ADDRESS &,Y' Zz 9J Class: 7.Miscellaneous QUANTITIES AND STORAGE (IN=indoors;OUT=outdoors) MAJOR MATERIALS i Case lots Dq.urns Above Tanks Undergn-ound IN OUT IN OUT IN OUT #&gallons Age Test Fu 2 2.) K asolin Jet Fuel(A) Diesel,Kerosene, #2 (B) Heavy Oils: waste motor oil(C) new motor oil(C) transmission/hydraulic Synthetic Organics: degreasers +t,A_..,K.9,vl cU/o ray 1-0 a Miscell neous: ev�c, el cq wf AL,40 DISPOSAL/RECLAMATION REMARKS: 1. Sanitary Sewage 2.Water Supply 114j o S i ..o , 4-&-1&.) O o-c a O Town Sewer (Public J&On-site OPrivate 3. Indoor Floor Drains YES NO�C O Holding tank:MDC_ ILA 7. �"" _ 0 t''t-,O` O Catch basin/Dry well L't 1,,,r' ® J'r`o� O On-site system 4. Outdoor Surface drains:YES NO 1L ORDERS: O Holding tank:MDC 44&A14 M SS o O Catch basin/Dry well O On-site system oy- /4e 5.Waste Transporter Name of Hauler Destination Waste Product YES NO a Per on(s) In erviewed' inspector Date TOWN OF BARNSTABLE COMPLIANCE: GLASS: 1.Marine,Gas Stations,Repair satisfactory 2.Printers BOARD OF HEALTH 3.Auto Body Shops O unsatisfactory- 4.Manufacturers COMPANYh ,°� (see"Orders") 5.Retail Stores yy���,,,, 6.Fuel Suppliers ADDRESS J im MA;lass: 7.Miscellaneous QUANTITIES AND STORAGE (IN= indoors;OUT=outdoors) MAJOR MATERIALS Case lots Drums Above Tanks Underground Tanks IN OUT IN OUT IN OUT #&gallons Age Test Fuels: Gasoline,Jet Fuel (A) Diesel, Kerosene, #2 (B) Heavy Oils: waste motor oil (C) I > new motor oil(C) 11 Pd transmission/hydraulic Synthetic Organics: degreasers Miscellaneous: DISPOSALIRECLAMATION REMARKS: 1. Sanitary Sewage 2.Water Supply O Town Sewer OPublic t1o",On-site OPrivate 3. Indoor Floor Drains YES NO L/ O Holding tank:MDC_ r� 0 Catch basin/Dry well 4 1"L O On-site system 4. Outdoor Surface drains:YES____NO ORDERS: Q Holding tank:MDC O Catch basin/Dry well O On-site system 5.Waste Transporter Name of Hauler Destination Waste Product 1. 1 YES INO 2. 17 P rson(s) Interviewed — Inspector Date TOWN OF BARNSTABLE COMPLIANCE: CLASS: 1.Marine,Gas Stations,Repa' satisfacto 2.Printers BOARD OF HEALTH ry 3.Auto Body Shops unsatisfactory- 4.Manufacturers COMPANYC W 1'.W t '6'09x --yam' (see"Orders") 5.Retail Stores —fir fi 6.Fuel Suppliers ADDRESS �/6 -✓�la� Lc1�y Class: 7.Miscellaneous QUANTITIES AND STORAGE (IN= indoors; OUT=outdoors) MAJOR MATERIALS -round Tanks IN OUT IN OUT IN OUT #&gallons Age Test Fuels: --Casoliire, ) �' -Die Ker #2 )- Heavy Oils: waste motor oil(C) _ new motor oil(C) transmission/hydraulic,w - Synthetic Organics: degreasers Miscellaneous: C - OA�i, � Q A = ll/ DISPOSALIRECLAMATION REMARKS: 1. Sanitary Sewage 2.W ter Supply O Town Sewer. ublic r �'On-site OPnvate 3. Indoor Floor Drains YES NO r O Holding tank:MDC � O Catch basin/Dry well r ° O On-site system 4. Outdoor Surface drains:YES N0_1/_ O ERS: O Holding tank:MDC O Catch basin/Dry well O On-site system 5.Waste Transporter Name of Hauler Destination Waste Product 2. Pers s) Interviewed Inspector Date K. 2i4rn1 ES od ^t.wJ ti No. -e9A6 I �'�� Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS s 2pplicatton for Migpogal *pgtem Con5tructtou Vermtt Application for a Permit to Construct( )Repair X)Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. (j�1-[ Lq I Owner's Name,Address and Tel.No. Assessor's Map/Parcel 01C Owl _V6� Installer's Name,Address,and Tel.No. CT V<1 Designer's Name,Address and Tel.No. I C Type of Building: Dwelling No.of Bedrooms _� Lot Size sq.ft. Garbage Grinder( ) Other Type of Building OTMCC No.of Persons Showers( ) Cafeteria( ) Other Fixtures :i�G1 ayol 1 Design Flow l 16 gallons per day. Calculated daily flow 14 1 gallons. Plan Date Number of sheets Revision Date Title t - t _ Size of Septic Tank, eo"AL -7 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 provisio f Title 5 of the Environmental Code and not to place the system in operation u til Certifi- cate of Compliance has been - f Health. Signed Date r106 Application Approved by Date Application Disapproved for t e following reasons 17 Permit No. IX20 h Date Issued No. ;"nd D66 y v ? Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: - PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS s ZIPPrication for Migool *patent Construction Permit Application for a Permit to Construct( )Repair)Upgrade( )Abandon( ) ❑Complete System El Individual Components Location Address or Lot No. fj'Ze� ,_ Q4 t Owner's Name,Address and Tel.No. Assessor's Map/Parcel l(AS tt,�� Installer's Name,Address,and Tel.No. 1 yfr "f A Designer's Name;'Ad'dress and Tel.No. Type of Building:. Dwelling No.of Bedrooms ' Lot`Size f : sq.ft. ._. — Garbage Grinder( ) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures '1 )n& �1 1•._ r Design Flow b gallons per day., calculated daily`flow` y gallons. Plan Date Number of sheets l f Revision Date Title Size of Septic Tank Type of S.A.S. A A2 Description of Soil Nature of Repairs or Alterations(Answer when applicable) r 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 provisio Title 5 of the Environmental Code and not to place the system in operation until Certifi- cate of Compliance has beRreasonos f Health. Signed Date .. Application Approved by Date°� Application Disapproved for e foll Permit No. =�!I 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(/V) Abandoned( )by 1 at X has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No dated Installer l'` Designer a- The issuance of this p 6sha11,not jbe construed asaa guarantee that the systtf-61will function as designed ./ Date �� Inspect<r-�� _ ,4--------------------------------------- No. 7 Fee 7 THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS 'Wi5po5ar &p5tem Construction Permit Permission is hereby granted to Construct( )Repair( UpgradeX )Abandon( ) System located at t(o CWti n7l )I 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 this permit. Date: 1 � — LU�o e�;, Approved by�9 �� f 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 PLANS) I, �1�U��(V1 ,� hereby ce ify that the application for disposal works construction permit signed by me dated , concerning the property located at l 1p F6wkt 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: fl A) Top of Ground Surface Elevation(using GIS information) B) G.W.Elevation +the MAX.High G.W.Adjustment. _ DIFF E-B•E-kEN d B 1. xx SIGNED : DATE: [Please Sketch proposed p an f s e ri-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 r ' )7Z► ° QIUIj O OF BARNSTABLE j LOCATION SEWAGE # VILLAGEf ASSESSOR'S MAP & LOTJO 9 44 + INSTALLER'S NAME&PHONE NO. (n Q, ``rr �✓L�s i SEPTIC TANK CAPACITY LEACHING FACILITY: (type) (size) NO. OF BEDROOMS BUILDER OROWNE46arrim PERMITDATE: COMPLIANCE DATE: 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 we exist within 300 fee of leaching facility) Feet Furnished by iib ,. .. , ,- �— Qejx,� x►Z