HomeMy WebLinkAbout1, 3 HIRAMAR ROAD - Health 1 &3 HIRAMAR RD., HYANNIS
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Commonwealth of Massachusetts a9a- 1N3
Title 5 Official Inspection Form
tip Subsurface Sewage Disposal System Form - Not for Voluntary Assessments i
1 & 3 Hiramar Road
Property Address
Eric Winer r"
Owner Owner's Name
information is required for every Hyannis ✓ MA 02601 09/24/2020'
page. City/Town State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:When filling out forms A. Inspector Information
on the computer,
use only the tab Michael T Bisienere
key to move your Name of Inspector
cursor-do not Cape Septic Inspections
use the return Company Name
key.
52 Rivers End Road
�y Company Address
Teaticket Ma. 02536
City/Town State Zip Code
Own 508-280-3356 , S13938
Telephone Number License Number
B. Certification
I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5
(310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address
listed above; the information reported below is true, accurate and complete as of the time of my
f inspection; and the inspection was performed based on my training and experience in the proper function
and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined .
that the system:
1. ® Passes
2. ❑ Conditionally Passes
3. ❑ Needs Further Evaluation by the Local Approving Authority
4. ❑ Fails
10/04/2020 .
Inspector's Signature e— ---
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board
of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of
10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate
regional office of the DEP. The original form should be sent to the system owner and copies sent to
the buyer, if applicable, and the approving authority.
I
Please note: This report only describes conditions at the time of inspection and under the
conditions of use at that time. This inspection does not address how the system will perform
in the future under the same or different conditions of use.
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18
Commonwealth of Massachusetts
Tithe 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
1 & 3 Hiramar Road
Property Address
Eric Winer
Owner Owner's Name
information is Hyannis MA 02601 09/24/2020
required for every y
page. Cityrrown State Zip Code Date of Inspection
C. Inspection Summary
Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6.
1) System Passes:
® I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
This duplex contains 4 bedrooms with an H-10 1000 gallon septic tank with an H-10 D-Box feeding 5
infiltrators with stone. At the time of the inspection no visible failure criteria was found. -
2) System Conditionally Passes:
❑ One or more system components as described in the "Conditional Pass" section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not".
determined," please explain.
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND (Explain below):
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
1 & 3 Hiramar Road
u
Property Address
Eric Winer
Owner Owner's Name
information is required for every Hyannis MA 02601 09/24/2020
page. Cityrrown State Zip Code Date of Inspection
C. Inspection Summary (cont.)
2) System Conditionally Passes (cont.):
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
3) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or'the environment.
a. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
I
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18
Commonwealth of Massachusetts
o Title 5 Official Inspection Form
�1 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
u—
1 & 3 Hiramar Road
Property Address
Eric Winer
Owner Owner's Name
information is required for every Hyannis MA 02601 09/24/2020
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
b. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well**.
Method used to determine distance:
**This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
c. Other:
4) System Failure Criteria Applicable to All Systems:
You must indicate "Yes" or"No" to each of the following for all inspections: r
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
I� Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
1 & 3 Hiramar Road
V
Property Address
Eric Winer
Owner Owner's Name
information is required for every Hyannis MA 02601 09/24/2020
—
page. Cityrrown State Zip Code Date of Inspection
C. Inspection Summary (cont.)
4) System Failure Criteria Applicable to All Systems: (cont.)
Yes No
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than '/z day flow
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply
well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis-f.[This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered. A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000 gpd-
10,000 gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
5) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the
questions in Section CA. �
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area—IWPA) or a mapped Zone II of a public water supply well
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18
Commonwealth of Massachusetts
�^ p Title 5 Official Inspection Form
I; Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
1 & 3 Hiramar Road
Property Address
Eric Winer
Owner Owner's Name
information is required for every Hyannis MA 02601 09/24/2020
page. Cityrrown State Zip Code Date of Inspection
C. Inspection. Summary (cont.)
If you have answered "yes" to any question in Section C.5 the system is considered a significant
threat, or answered "yes"to any question in Section CA above the large system has failed. The
owner or operator of any large system considered a significant threat under Section C.5 or failed
under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner
should contact the appropriate regional office of the Department.
6. You must indicate "yes" or"no"for each of the following for all inspections:
Yes No
r ® ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
® ❑ Has the system received normal flows in the previous two week period?
El N Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,"-"
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑ Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS) on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
Determined in the field (if any of the failure criteria related to Part C is at issue
® ❑ approximation of distance is unacceptable) [310 CMR 15.302(.5)]
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
............ !% 1 & 3 Hiramar Road
u—
Property Address
Eric Winer
Owner Owner's Name
information is required for every Hyannis annis MA 02601 09/24/2020
page. City/Town State Zip Code Date of Inspection
D. System Information
1. Residential Flow Conditions:
Number of bedrooms (design): 4 Number of bedrooms (actual): 4
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 plus
GPD
Description:
Number of current residents: 6
Does residence have a garbage grinder? ❑ Yes ® No
.tr
Does residence have a water treatment unit? ❑ Yes ® No
If yes, discharges to:
Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No
information in this report.)
Laundry system inspected? ❑ Yes ® No
Seasonal use? ❑ Yes ® No
Water meter readings, if available last 2 ears usage Town water
9 ( Y 9 (gpd))�
Detail:
# 1 used 73,304 gallons from 2/25/19 to 9/3/2020 and #3 used 67,320 gallons from 2/25/19 to
9/3/2020
Sump pump? ❑ Yes ® No
Last date of occupancy: occupied
Date
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
u
1 & 3 Hiramar Road
Property Address
Eric Winer
Owner Owner's Name
information is required for every Hyannis MA 02601 09/24/2020
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
2. Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Water treatment unit present? ❑ Yes ❑ No
If yes, discharges to:
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
Last date of occupancy/use: Date
Other(describe'below):
3. Pumping Records:
Source of information:
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
1 & 3 Hiramar Road
Property Address
Eric Winer
Owner Owner's Name
information is required for every Hyannis MA 02601 09/24/2020
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
4. Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner) and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
Approximate age of all components, date installed (if known) and source of information:
Were sewage odors detected when arriving at the site? ❑ Yes ® No
5. Building Sewer(locate on site plan):
Depth below grade: 27"feet
Material of construction:
❑ cast iron ® 40 PVC two pipes
❑ other(explain):
"} Distance from private water supply well or suction line: Town water
feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
Water was flushed and came freely.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
lip Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
u
1 & 3 Hiramar Road
Property Address
Eric Winer
Owner Owner's Name
information is required for every Hyannis MA 02601 09/24/2020
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
6. Septic Tank (locate on site plan):
Depth below grade: 18"feet
Material of construction:
® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions: H-10 1000 gallon
Sludge depth:
2"
Distance from top of sludge to bottom of outlet tee or baffle
34"
1
Scum thickness
5„
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
13"
How were dimensions determined? sludge judge
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
I recommend the new owner put the septic tank on a maint. plan with a local septic pumping co.
based on the future use of the home. At the time of inspection the liquid level was at working level
and the tee's were in place.
t5insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 18
Commonwealth of Massachusetts
_ ,z Title 5 Official Inspection Form
`1 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
1 & 3 Hiramar Road
Property Address
Eric Winer
Owner Owner's.Name
information is required for every Hyannis MA 02601 09/24/2020
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
7. Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
8. Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity:
gallons
Design Flow:
gallons per day
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 18
Commonwealth of Massachusetts
,to Title 5 Official Inspection Form
I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
1 & 3 Hlramar Road
Property Address
Eric Winer
Owner Owner's Name
information is required for every Hyannis MA 02601 09/24/2020
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
8. Tight or Holding Tank(cont.)
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
"Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
9. Distribution Box(if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert
0"
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
At the time of the inspection the liquid level was at working level and there were no visible signs of
leakage or solids carryover.
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 18
f
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
V 1 & 3 Hiramar Road
Property Address
Eric Winer
Owner Owner's Name
information is required for every Hyannis MA 02601 09/24/2020
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
10. Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No*
Alarms in working order: ❑ Yes ❑ No*
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
* If pumps or alarms are not in working order, system is a conditional pass.
11. Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
,,,v.
Type:
❑ leaching pits number:
❑ leaching chambers number:
-., ❑ leaching galleries number:
® leaching one w/5 trenches number, length: infiltrators
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18
1,
Commonwealth of Massachusetts
to Title 5 Official Inspection Form
1 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
u
1 & 3 Hiramar Road
Property Address
Eric Winer
Owner Owner's Name
information is required for every Hyannis MA 02601 09/24/2020
page. CityTrown State Zip Code Date of Inspection
D. System Information (cont.)
11. Soil Absorption System (SAS) (cont.)
T' Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
At the time of the inspection no visible failure criteria was found.
12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18
L ,
Commonwealth of Massachusetts
p Title 5 Official Inspection Form
I; Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
u—
1 & 3 Hiramar Road
Property Address
Eric Winer
Owner Owners Name
information is Hyannis MA 02601 09/24/2020
required for every y
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
13. Privy(locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil,,signs of hydraulic failure, level of ponding, condition of vegetation,
cr etc.):
I
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
1 &3 Hiramar Road
Property Address
Eric Winer
Owner Owner's Name
information is
required for every Hyannis MA 02601 09/24/2020
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
14. Sketch Of Sewage Disposal System:
Provide a view of the sewage disposal system, including ties to at least two permanent reference
landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters
the building. Check one of the boxes below:
® hand-sketch in the area below
❑ drawing attached separately
F-T. I
A3 y4• ,
0
83_'
I
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18
f
Commonwealth of Massachusetts r
In Title 5 Official Inspection Form
<ii; Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
1 & 3 Hiramar Road
u
Property Address
Eric Winer
Owner Owner's Name
information is required for every Hyannis MA 02601 09/24/2020
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
15. Site Exam:
® Check Slope
® Surface water
® Check cellar
® Shallow wells
Estimated depth to high ground water: 10 plus feet
feet
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from system design plans on record
If checked, date of design plan reviewed: Date
® Observed site(abutting property/observation hole within 150 feet of SAS)
❑ Checked with local Board of Health -explain:
❑ Checked with local excavators, installers- (attach documentation)
❑ Accessed USGS database -explain:
You must describe how you established the high ground water elevation:
I augered a hole at a lower elevation and shot it with a transit.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 18
Commonwealth of Massachusetts
:. Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
1 & 3 Hiramar Road
V�
Property Address
Eric Winer
Owner Owner's Name
information is required for every Hyannis MA 02601 09/24/2020
page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
Complete all applicable sections of this form inclusive of:
® A. Inspector Information: Complete all fields in this section.
® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked
® C. Inspection Summary:
1, 2, 3, or 5 completed as appropriate
4 (Failure Criteria) and 6 (Checklist) completed
® D. System Information:
For 8: Tight/Holding Tank—Pumping contract attached
For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached
For 15: Explanation of estimated depth to high groundwater included
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 18 of 18
R
Certified Mail#7005 1160 0000 0191 0362
�oFZHEro�ti Town of Barnstable
Regulatory Services
naausranLF.,
9 MASS. m Thomas F. Geiler, Director
� i6gq
Public Health Division
Thomas McKean, Director
200 Main Street, Hyannis, MA 02601
Office: 508-862-4644 Fax: 508-790-6304
January 30, 2008
Murphy Family Real Estate
25 Pierrepont Road
Winchester, MA 01890
NOTICE TO ABATE VIOLATIONS OF 105 CMR 410.000, STATE SANITARY
CODE II — MINIMUM STANDARDS OF FITNESS FOR HUMAN HABITATION
AND THE TOWN OF BARNSTABLE CODE CHAPTER 170.
The property owned by you located at 60 Fresh Holes Road Hyannis, was inspected
on January 25, 2008 by Timothy O'Connell, Health Inspector for the Town of
Barnstable. This inspection was conducted on the basis of the rental registration in
accordance with Chapter 170 of the Town of Barnstable Code.
The following violations of the State Sanitary Code were observed:
105 CMR 410.500— Owner's Responsibility to Maintain Structural Elements. Storm
door in need of replacement;broken window in living room.
The following violations of the Town of Barnstable Code were observed:
1§ 70-10— Smoke Detectors and Carbon Monoxide Alarms. No operable smoke
detectors or carbon monoxide alarms at time of inspection.
You are directed to correct the violations listed above within twenty-four (24) hours
of your receipt of this notice by installing smoke detectors and.CO alarms in
accordance with Mass State Fire Codes. You are directed to correct the violations
listed above within thirty (30) days of your receipt of this notice by replacing storm
.door and by repairing broken window.
QAOrder letters\Housing violations\Rental ordinance\60 Fresh Holes Road.doc
I
l
You may request a hearing before the Board of Health if written petition requesting same
is received within ten (10) days after the date the order is served.
Non-compliance will result in a fine of $100.00 per violation. Each day's failure to
comply with an order shall constitute a separate violation.
Should you have any questions regarding the above violations, please contact the Town
Health Division and ask to speak with the inspector who performed the inspection.
PER ORDER OF TH BOARD OF HEALTH
omas A. McKean, R.S., CHO
Director of Public Health
Town of Barnstable
Cc: Timothy O'Connell, Health Inspector
Dennis Connors, Owner's Rep.
QAOrder letters\Housing violations\Rental ordinance\60 Fresh Holes Road.doc
FORM30 C&w HOBBS&WARREN'"
THE COMMONWEALTH OF MA=SSACHUSETTS
BOAR
� TH
CITY/TOWN
W
b S D PARTMENT
c, ADDRESS
GSM yey`0
TELEPHONE
/9 I
Address r v t Occupan `
Floor Apartment No. No.of Occupants
No. of Habitable Rooms No.Sleeping Rooms
No. dwelling or rooming unit No.StQrie
t.Name and address of owner �� )�GV� .
Remarks Reg. Vio.
YARD Out Bld s.: Fences.-
Garbage and Rubbish
Containers:
Drainage
Infestation Rats or other:
STRUCTURE EXT. Steps,Stairs, Porches: — [v
Dual Egress:and Obst'n.:
❑ B ❑ F ❑ M Doors.Windows:
Roof
Gutters, Drains:
Walls: �—
Foundation:
Chimney:
BASEMENT Gen.Sanitation:
Dampness:
Stairs:
Lighting:
STRUCTURE INT. Hall,Stairway:
Obst'n.:
Hall, Floor,Wall,Ceiling:
Hall Lighting:
Hall Windows:
HEATING Chimneys:
Central ❑ Y ❑ N Equip. Repair
TYPE: Stacks, Flues,Vents:
PLUMBING: Supply Line:
❑ MS ❑ ST ❑ P Waste Line:
H.W.Tanks Safety and Vent(s)
ELECTRICAL Panels, Meters,Cir.:
❑ 110 ❑ 220 Fusing,Grnd.:
AMP: Gen. Cond. Distrib. Box:
Gen. Basement Wiring:
DWELLING UNIT
Ventil. L to Outlets Walls Ceils. Wind. Doors Floors Locks
Kitchen
Bathroom
Pantry
Den
Living Room
Bedroom 1 L
Bedroom 2
Bedroom 3
Bedroom 4
Hot Water Facil. Su .Ten.,Gas, Oil, Elect.:
Stacks, Flues,Vents,Safeties:
Kitchen Facilities Sink
Stove
Bathing,Toilet Facil. Vent., Plumb.,Sanit'n.:
Wash Basin,Shower or Tub: Q S�
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 PORT IS SIGNED AND CERTIFIED UNDER T PAINS AND
PENALTIES OF PE JU
INSPECTOR TITLE v
A.M:
DATE ^' o TIME f ' P.M•
A.M.
THE NEXT SCHEDULED REINSPECTION P.M.
r .Va;qw.,h ^F;'�:,.'.''s..y.... a.,..,�'>.. ,.v.. r a:;: ,..•r.: 7et:{r . _ r .
i'
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 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 Ieadbased 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.
I
Town of Barnstable
Regulatory Services
naxtvARL Thomas F. Geiler, Director
MASS.
•b'� 1,� Public Health Division
Arrb AAA a,
Thomas McKean,Director
200 Main Street, Hyannis, MA 02601
Office: 508-862-4644 Fax: 508-790-6304
January 25, 2008
Attn: Hyannis Fire
On January 25, 2008, Health Inspectors Timothy B. O'Connell investigated a rental
property. In accordance with the State Sanitary Code, 105 CMR 410.482, the Health
Department is required to notify the Fire Department if there is a smoke detector
violation, or possible smoke detector violation.
The following property had possible smoke detector and CO detector violations:
58 Fresh Holes Road, Hyannis,Assessors Map-Parcel: (292-173):
-Inoperable smoke detector present(no battery)
-No CO detector
1 & 3 Fresh Holes Road, Hyannis,Assessors Map-Parcel: (292-157):
-No CO in either unit and lack of Smoke Detectors in both units.
5 & 7 Fresh Holes Road, Hyannis, Assessors Map-Parcel: (292-156):
-No CO or Smoke Detector in unit 7 which is vacant.
-No CO present in unit 5.
Timothy O 'Connell-Healt Inspector
I
QAOrder letters\Housing violations\Rental ordinance\\Fire Violations\58 Fresh Holes
i
i
;;rtl
Certified Mail#7005 1160 0000 0191 0362
P�OFTHE Tp Town of Barnstable
�0-%l Regulatory Services
I(* BARNST BL-. I
�A55. m Thomas F. Geiler, Director
039.
Arf°-"A Public Health Division
Thomas McKean,Director
200 Main Street, Hyannis, MA 02601
Office: 508-862-4644 Fax: 508-790-6304
January 30 2008
Murphy Family Real Estate
25 Pierrepont Road
Winchester, MA 01890
NOTICE TO ABATE VIOLATIONS OF 105 CMR 410.000, STATE SANITARY
CODE II - MINIMUM STANDARDS OF FITNESS FOR HUMAN HABITATION
AND THE TOWN OF BARNSTABLE CODE CHAPTER 170.
The property owned by you located at 7 Fresh Holes Road Hyannis, was inspected
on January 25, 2008 by Timothy O'Connell, Health Inspector for the Town of
Barnstable. This inspection was conducted on the basis of the rental registration in
accordance with Chapter 170 of the Town of Barnstable Code.
The following violations of the State Sanitary Code were observed:
105 CMR 410.500— Owner's Responsibility to Maintain Structural Elements. Floor
needs to be replaced (i.e. rug); wall needs repainting.
The following violations of the Town of Barnstable Code were observed:
170-10 —Smoke Detectors and Carbon Monoxide Alarms. No operable smoke
detectors or carbon monoxide alarms at time of inspection.
You are directed to correct the violations listed above within twenty-four (24) hours
of your receipt of this notice by installing smoke detectors and CO alarms in
accordance with Mass State Fire Codes. You are directed to correct the violations
listed above within thirty (30) days of your receipt of this notice by repairing floor
and by painting.
QAOrder letters\Housing violations\Rental ordinance\7 Fresh Holes Road.doc
You may request a hearing before the Board of Health if written petition requesting same
is received within ten (10) days after the date the order is served.
Non-compliance will result in a fine of $100.00 per violation. Each day's failure to
comply with an order shall constitute a separate violation.
Should you have any questions regarding the above violations, please contact the Town
Health Division and ask to speak with the inspector who performed the inspection.
PER ORDER THE BOARD OF HEALTH
T- as A. McKean, R.S., CHO
Director of Public Health
Town of Barnstable
Cc: Timothy O'Connell,Health Inspector
Dennis Connors, Owner's Rep.
QAOrder letters\Housing violations\Rental ordinance\7 Fresh Holes Road.doc
FORM30 H&W HOBBsB WARREN TM THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HE LTH
CITY/TOWN,
W
ft DEPARTMENT -
�� ADDRESS
°�+r Syey`er
�j TELEPHONE
Address 1 —` Occupant__I /, -, 47
Floor Apartment No. No. of Occupants
No. of Habitable Rooms No.Sleeping Rooms
No.dwelling or rooming units No.Stonqs ��
Name and address of owner
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:
Roo`
Gutters, Drains:
Walls:
Foundation:
Chimney:
BASEMENT Gen.Sanitation:
Dampness:
Stairs:
Lighting:
STRUCTURE INT. Hall,Stairway:
Obst'n.:
Hall, Floor,Wall,Ceiling: 5C7v
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 Paneis, Meters,Cir.:
❑ 110 ❑ 220 Fusing,Grnd.:
AMP: Gen.Cond. Distrib. Box:
Gen. Basement Wiring:
DWELLING UNIT
Ventil. L to . Outlets Walls Ceils. Wind. Doors Floors Locks
Kitchen
Bathroom
Pantry
Den
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 RE OwRT IS SIGNED AND CERTIFIED UNDER THE PAINS AND
PENALTIES OF PERJ ,
INSPECTOR �[) TITLE
A.M.
DATE I v-il TIME i
y '� 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 Vz exist in residential premises, shall bo 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 ||. 105CIVIR41O.1O0 through 41O.02U state minimum requirements of fitness for
human hubitation, any other violation has the potential to fall within this category in any given specific situation but may not d000
in every case and therefore is not included in this listing. Failure to include shall in noway be construed aoa determination that
other violations orconditions may not b*found to fall within this category. Nor shall failure to include affect the duty ofthe local
health official to order repair or correction of such violation(s) pursuant to 105 CIVIR 410.830 through 410.833 nor shall failure to
include affect the legal obligation of the person 0»whom the order ix issued to comply with such order.
(\) Failure to provide asupply of water sufficient in quantity, pressure and temperature, both hot and cold, to meet the ordinary .
needs of the occupant in accordance with 105 CIVIR 410.180 and 410.190 for a period of 24 hours or longer.
(B) Failure to provide heat as required by 105 CIVIR 410.201 or improper venting or use ofaspace heater orwater heater as
prohibited by 1O5CIVIR41020O(8)and 41O.2O2
(C) Shutoff and/or failure 10 restore electricity orgas.
(D) Failure Vz provide the electrical facilities required by105CIVIR41U.25O(B). 41O251(A). 410.253 and thelighhngin com-
mon amarequinedby1O5CIVIR410254.
(B Failure to provide a safe supply ofwater.
(F) Failure Vo provide o toilet and maintain a sewage disposal system in operable condition ao required by1U5CMR
41O150KV(1)and 41O.30O.
(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 CIVIR 410.450, 410.451 und41O.452.
(H) Failure 0x comply with the security requirements cd1O5CIVIR410.48O(D).
(|) Failure ko comply with any provisions of 105 CIVIR 410.000. 410.601 or41U.OU2which results in any accumulation ofgar-
Uago, mbbioh,filth m other causes of sickness which may provide afood source or harborage for mdonts, insects or other pests
or otherwise contribute to accidents orVo the creation or spread of disease.
(J) The presence of 16adbased paint on a dwelling,or dwelling unit in violation of the Massachusetts Department of Public
Health Regulations for-Lead Poisoning Prevention and Control, 105CIVIR480.000. (See M.G.Lo. 111 @@> 1OO through 1AQj
(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 10 health o/safety. �
�
(L) Failure to install o|ootriod, p|umbing, heating and gas-burning facilities in accordance with accepted plumbing, heating, �
gas-fitting and o|outrioa|wiring standards or failure Vo maintain such faoihiooaaare required by 105 CIVIR 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 orwhich may result inthe release of powdorod, crumbled or pulverized aoUoatoo material in violation of 105
CIVIR41O.353.
(N) Failure to provide u smoke detector required by 105 SIVIR 410.482.
O) 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 mconditions:
(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 p|umbing, heging,guufi8ing, or electrical wiring standards that do not create an immediate hazard.
(4) Failure to maintain uoafe handrail or pmteuVwo railing for every stairway, porch baloony, roof orsimilar place as
required by 105CIVIR41U.503(\)and 41O.5U3(B).
(5) Failure 1n eliminate rodents, 000kmaohoo, insect infestations and other pests uarequired by 105CIVIR410.550.
(P) Any other violation of 105 CIVIR 410.000 not enumerated in 105 CIVIR 410.750KV1hmugh (0)shall be deemed to boo con-
dition whiohmayondangerormateriu||yimpairthohoa|thoroufetyandwmU'boingofan000upantuponthofai|u,00f the owner �
Vz remedy said condition within the time oo ordered by the Board ofHealth. �
�
�
�
' UNITED STATES P �TAL,.$ER1(I r - i" AN1ail
M lid x o C 10
��
• Sender: Please print your name, address,4and ZIP+4'in this lion •
Town of Barnstable
g Health Division ,; c-n
200 Main Street ;
Hyannis,MA 02601 z
!!!!i!l1411��9}i�ti{{tlt�{�.tti�'1tilltil!!{4I��tf}' tf!l�t�}'
SENDER: COMPLETE THIS SECTION COMPLETE THIS SECTION ON DELIVERY
N Complete items 1*.2,and 3.Also complete A. Signature
Item 4 ifRestricted%Delivery is desired. ❑Agent
—{�
■ Print your name and address on the reverse X f" ❑Addressee
so that we can return the card to you. B. Race i by(Printed Name) C. to of iv
■ Attach this card to the back of the mailpiece,
or on the front if space permits.
D. Is delivery address different from item 1? Y
1. Article Addressed to: If YES,enter delivery address below: ❑No
t..� Q b f (V\A b 2 0 3. Service Type
12 Certified Mail ❑Express Mail
❑Registered 15Return Receipt for Merchandise
❑Insured Mail ❑C.O.D.
I` 4. ResMcted.Delivery?oft Fee),
2. Article Number ¢_ TIP—' y 16 - PO 3 5.5.;i
(transfer from service iabeo (
PS Form 3811,February 2004 Domestic Return Riceipt 162595-o2w-i54o
Certified Mail#7005 1160 0000 0191 0355
r4cvvl_,�,
+EwtiTown of Barnstable
��T= ); Regulatory Services
;i•KRUAIRINSTABLE,,-
QS,. a Thomas F. Geiler Director
b. ,MA�A� Public Health Division
Thomas McKean, Director
200 Main Street, Hyannis, MA 02601
Office: 508-862-4644 Fax: 508-790-6304
January 30, 2008
Anthony Aliberti
11 Rainbow Pond Drive
Walpole, MA 02081
NOTICE TO ABATE VIOLATIONS OF 105 CMR 410.000 STATE SANITARY
CODE Il — MINIMUM STANDARDS OF FITNESS FOR HUMAN HABITATION
AND THE TOWN OF BARNSTABLE CODE CHAPTER 170.
The property owned by you located.at 1 & 3 Fresh Holes Road Hyannis, was inspected
on January 25, 2008 by Timothy O'Connell, Health Inspector for the Town of -
Barnstable. This inspection was conducted on the basis of the rental registration in
accordance with Chapter 170 of the Town of Barnstable Code.
The following violations of the Town of Barnstable Code were observed:
170-10—Smoke Detectors and Carbon Monoxide Alarms. No operable smoke
detectors or carbon monoxide alarms.
You are directed to correct the violations listed above within twenty-four (24) hours
of your receipt of this notice by installing smoke detectors and carbon monoxide
alarms in accordance with Mass State Fire Codes.
You may request a hearing.before the Board of Health if written petition requesting same
is received within ten (10) days after the date the order is served.
Non-compliance will result in'a fine of $100.00 per violation. Each day's failure to
comply with an order shall constitute a separate.violation.
M
Q:\Order letters\Housing violations\Rental ordinance\l&3 Fresh Holes Road.doc
t
Should you have any questions regarding the above violations, please contact the Town
Health Division and ask to speak with the inspector who performed the inspection.
PER ORDER OF T BOARD OF HEALTH
Thomas A. McKean, R.S., CH
Director of Public Health
Town of Barnstable
Cc: Timothy O'Connell, Health Inspector
Dennis Connors, Owner's Rep.
Q:1Order letters\Housing violation s\Rental ordinance\1&3 Fresh Holes Road.doc „
FOaM30 C&w Homs&WARREN TM THE COMMONWEALTH OF MASSACHUSETTS j
BOARD OF HE , TH
CITY/TOWN !�
W
DEPARTMENT t
ADDRESS
G,,M SVey`0W .
iE EPHONE 1
Address � ` — OccupantT
Floor Apartment No. No.of Occupants
No.of Habitable Rooms No.Sleeping Rooms
No.dwelling or rooming units__ No.Stories
Name and address of owner J'
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:
Dampness:
Stairs:
Lighting:
STRUCTURE INT. Hall,Stairway:
Obst'n.:
Hall, Floor,Wall,Ceiling:
Hall Lighting:
Hall Windows:
HEATING -Chimneys: -
Central ❑ Y ❑ N Equip. Repair
TYPE: Stacks, Flues,Vents:
PLUMBING: Supply Line:
❑ MS ❑ ST ❑ P Waste Line:
H.W.Tanks Safety and Vent(s)
ELECTRICAL Panels, Meters,Cir.:
❑ 110 ❑ 220 Fusing,Grnd.:
AMP: Gen.Cond. Distrib. Box:
Gen. Basement Wiring:
DWELLING UNIT
Ventil. L to Outlets Walls Ceils. Wind. Doors Floors Locks
Kitchen
Bathroom
Pantry
Den
Living Room 60
Bedroom 1
Bedroom 2
Bedroom 3
Bedroom 4
Hot Water Facil. Sup.Ten.;Gas, Oil, Elect.:
St cks;Flues,Vents,Safeties:
Kitchen Facilities i
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 VIC TIO 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 RE T17T JS SIGNED AND CERTIFIED UNDER THE PAINS AND
PENALTIES OF PER, "
INSPECTOR TITLE i
DATE b TIME P.M.
A.M.
THE NEXT SCHEDULED REINSPECTION � P.M.
410.750: Conditions Deemed to Endanger or Impair Health or Safety
The following conditions, when found to exist in residential premises,shall be deemed conditions which may endanger or
impair the health, or safety and well-being of a person or persons occupying the premises.This listing is composed of 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.
FORM 30 C&W HOBBS&WARRENTM THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEAL H
ITY/TOWN
W
D PARTMENT �
�V®raw.►
ADDRESS
TELEPHONE
n 1 y
Address l — Occupant /
Floor Apartment No. No. of Occupants
No.of Habitable Rooms 1 No.Sleeping Rooms
No.dwelling or rooming units_ No.Stories
Name and address of owner AUsu
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:
Dampness:
Stairs:
Li htin :
STRUCTURE INT. Hall,Stairway:
Obst'n.:
Hall, Floor,Wall,Ceiling:
Hall Lighting:
Hall Windows:
HEATING Chimneys:
Central ❑ Y ❑ N Equip. Repair
TYPE: Stacks, Flues,Vents:
PLUMBING: Supply Line:
❑ MS ❑ ST ❑ P Waste Line:
H.W.Tanks Safety and Vent(s)
ELECTRICAL Panels, Meters,Cir.:
❑ 110 ❑ 220 Fusing,Grnd.:
AMP: Gen.Cond. Distrib. Box:
Gen. Basement Wiring:
DWELLING UNIT
Ventil. L to . Outlets Walls Ceils. Wind. Doors Floors Locks
Kitchen
Bathroom
Pantry
Den
Living Room
Bedroom 1
Bedroom 2
Bedroom 3
Bedroom 4
Hot Water Facil. Sup.Ten.,Gas,Oil, Elect.:
l.lacks, Flues, ents,Safeties:
Kitchen Facilities 1011
8t6ve
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 VU
Locks on Doors:
ONE OR MORE OF THE VIOLATION 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 REP RT IS SIGNED AND CERTIFIED UNDER THE PAINS AND
PENALTIES OF PER D
INSPECTOR TITLE
DATE , s TIME 0 ` �" P.M.
A.M.
THE NEXT SCHEDULED REINSPECTION t 1 / P.M.
{
410.750: Conditions Deemed to Endanger or Impair Health or Safety
The following conditions,when found to exist in residential premises, shall be deemed conditions which may endanger or
impair the health, or safety and well-being of a person or persons occupying the premises. This listing is composed of 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.
DAR
I UNITED STATES <".:. '::ti:'
6 MI - III
n dam ,r�t5lo. 10 i
• Sender: Please print your name, address, and ZIP+4 in this box •
I I
Town of Barnstable
I
f Health Division .
I $O� 200 Main Street
I ` Hyannis,MA 02601
1iyiii11liii1111till
SECTION,ON DELIVERY
■ Complete items 1,2,and 3.Also complete A. Signature
item 4 if Restricted Delivery is desired. ✓-L �ent
■ Print your name and address on the reverse ` ❑Addressee 1
so that we can return the card to you. B. Received by(PrinCW Name) .C. Date of Delivery
■ Attach this card to the back of the mailpiece, F
or on the front if space permits. ! =0 -,1 -•� 1
N D. Is delivery address different from9 ern 1?-,❑Yes
1. Article Addressed to: If YES,enter delivery address below: No
e:c c �`t{:�.,�- �Z•mac` � �. T.,
py
•t C,�t� t ,Mj� 0 t a� 3. Service Type 00i
OPCertifled Mail Expres all
❑Registered Return Receipt for Merchandise
❑Insured Mail C.O.D.
4. Restricted Delivery?.(Extra-F�1- 1 ❑Yes
2. Article Number i J ; r '' 116�} 00 GO i �191 036.2
7aa5, . M ;
(Transfer from service labeg
I; PS Form 3811,February 2004 Domestic Return Receipt \, 102595-02-M-154
i
Certified Mail#7005 1160 0000 0191 0362
�o,VHE rows Town of Barnstable
Regulatory Services
IlAE A[3LE, � - ,
9 SS. Thomas F. Geiler, Director
t6 0
Public Health Division
Thomas McKean, Director
200 Main Street, Hyannis, MA 02601
Office: 508-862-4644 Fax: 508-790-6304
January 30, 2008
Murphy Family Real Estate
25 Pierrepont Road
Winchester, MA 01890
NOTICE TO ABATE VIOLATIONS OF 105 CMR 410.000, STATE SANITARY
CODE II — MINIMUM STANDARDS OF FITNESS FOR HUMAN HABITATION
AND THE TOWN OF BARNSTABLE CODE CHAPTER 170.
The property owned by you located at 5 Fresh Holes Road Hyannis, was inspected
on January 25, 2008 by Timothy O'Connell,'Health Inspector for the Town of
Barnstable. This inspection was conducted on the basis of the rental registration in
accordance with Chapter 170 of the Town of Barnstable Code.
The following violations of the State Sanitary Code were observed:
105 CMR 410.500— Owner's Responsibility to Maintain Structural Elements. Floor
in bedroom needs to be finished;toilet needs back cover.
The following violations of the Town of Barnstable Code were observed:
170-10—Smoke Detectors and Carbon Monoxide Alarms. No carbon monoxide
alarm at time of inspection.
You are directed to correct the violations listed above within twenty-four (24) hours
of your receipt of this notice by installing CO alarms in accordance with Mass State
Fire Codes. You are directed to correct the violations listed above within thirty (30)
days of your receipt of this notice by finishing bedroom floor and providing cover
for toilet.
QAOrder letters\Housing violations\Rental ordinance\5 Fresh Holes Road.doc
You may request a hearing before the Board of Health if written petition requesting same
is received within ten (10) days after the date the order is served.
Non-compliance will result in a fine of $100.00 per violation. Each day's failure to
comply with an order shall constitute a separate violation.
Should you have any questions regarding the above violations, please contact the Town
Health Division and ask to speak with the inspector who performed the inspection.
PER ORDER OF E BOARD OF HEALTH
omas A. McKean, R.S., CHO
Director of Public Health
Town of Barnstable
Cc: Timothy O'Connell, Health Inspector
Dennis Connors, Owner's Rep.
i
QAOrder letters\Housing violations\Rental ordinance\5 Fresh Holes Road.doc
,i-FORM30 C&W HOBBS&WARREN'" THE COMMONWEALTH OF MASSACHUSETTS
BOARD F H
CITY/TOWN
W
D PARTMENT �
ADDRESS
^M SVOy`ow
S �/Z.Q� lC� TELEPHONE
Address Occupant
Floor Apartment No. No.of Occupants
:V�
No.of Habitable Rooms No.Sleeping Rooms
-
No.dwelling or rooming units No.Stories .
Name and address of owner
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:
Dampness:
Stairs:
Lighting: <
STRUCTURE INT. Hall,Stairway:Obst'n.:
Hall, Floor,Wall,Ceiling:
Hall Lighting:
Hall Windows:
HEATING Chimneys:
Central ❑ Y ❑ N --E ui :�Re air
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 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.:
Sta,cks, Flues,Vents,Safeties:
Kitchen Facilities in
ve
Bathing, oil Facil. Vent., Plumb.,Sanit'n.:
Wash Basin,Shower or Tub:
Infestation Rats, Mice, Roaches or Other:
Egress Dual and Obst'n:
General Building Posted
Locks on Doors:
ONE OR MORE OF THE VIOLATIONS CHECKED ABOVE IS A CONDITION WHICH
MAY MATERIALLY IMPAIR THE HEALTH OR SAFETY AND WELL-BEING OF THE
OCCUPANT AS DETERMINED BY 105CMR 410.750 OF THE CODE OR THE
AUTHORIZED INSPECTOR. (See Over)
"THIS INSPECTION REPORT IS SIGNED AND CERTIFIED UNDER THE PAINS AND
PENALTIES OF PERJU, ."' e-
INSPECTOR TITLE --�
M
DATE �' TIME �'' P.M.
A.M.
THE NEXT SCHEDULED REINSPECTION P.M.
c�
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 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.
(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 410.15.0(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.
UNIfLUSTATES 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•
'town of Barnstable
!Jeatth Division
I J 200 Main Street f
Hyannis.MA 0260i
I
M
COMPLETE • • • • DELIVERY
■ Complete items 1,2,and .'A sb c rhp eta ' I FA.°Sin u ° !item 4 if Restricted Delivery is desired. ❑,Agent
■ Print yourname and address on the reverse Addressee
so that we can return the card to you. B. Re ived by_(Prin 'd e) C. f Deivery
■ Attach this card to the back of the mailpiece, ,�'•'
or on the front if space permits.
D. Is delivery address different from item 11 Yes
1. Article Addressed to: If YES,enter delivery address below: ❑No
G t-�C.
ytA I> 2�a
3. Service Type 0141.5b
®Certified Mail ❑Express Mail
❑Registered 0 Retum Receipt for Merchandise
❑Insured Mail ❑C.O.D.
4. Restricted Delivery?(Extra Fee) ❑Yd-.
2..Article Number i 7 — 16 8 0 ;0 0 4 i 5 4 581. 4 7 91 s
(rmnsfer from serv/ce h660
PS Form 3811;February 2004 "Domestic Return Receipt 102595-02-M-1540
Certified Mail#7003 1680 0004 5458 4791
�z rati Town of Barnstable
BARN�STABLE,� Regulatory Services — ---
� MAC' Thomas F. Geiler,Director
a i639• p��
Public Health Division
Thomas McKean, Director
200 Main Street, Hyannis, MA 02601
Office: 508-862-4644 Fax: 508-790-6304
July 3, 2007
Eric Winer
144 Barton Road
Hodgdon, ME 04730
NOTICE TO ABATE VIOLATIONS OF 105 CMR 410.000, STATE SANITARY
CODE II — MINIMUM STANDARDS OF FITNESS FOR HUMAN HABITATION
AND THE TOWN OF BARNSTABLE CODE CHAPTER 170.
The property owned by you located at 3 Hiramar Road Hyannis, was inspected
on July 2, 2007 by Thomas McKean, Health Agent for the Town of Barnstable. This
inspection was conducted on the basis of the rental registration in accordance with
Chapter 170 of the Town of Barnstable Code.
The following violations of the State Sanitary Code were observed:
105 CMR 410.351 —Owner's Installation and Maintenance Responsibilities. Oven is
rusted in various places and believed to be leaking gas (slight odor of gas observed at
time of inspection).
105 CMR 410.552—Screens for Doors. No screens provided for front or rear doors.
You are directed to correct the violations listed above within thirty(30) days
of your receipt of this notice by repairing oven by removing rust and preventing gas
leaks or by replacing oven and by providing screens for front and rear doors.
You may request a,hearing before the Board of Health if written petition requesting same
is received within ten (10) days after the date the order is served.
Non-compliance will result in a fine of $100.00 per violation. Each day's failure to
comply with an order shall constitute a separate violation.
Q:\Order letters\Housing violations\Rental ordinance\3 Hiramar Road.doc
Should you have any questions regarding the above violations, please contact the Town
Health Division and as to speak with the inspector who performed the inspection.
ER OF THE OARD OF HEALTH '
omas A. McKean, R.S., CHO
Director of Public Health
.Town of Barnstable
Q:\Order letters\Housing violations\Rental ordinance\3 Hiramar Road.doc
i
FORM 30 C&w HOBBS&WARREN TM THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
CITY/TOWN
a & ARTMENT
<2� ID M
�G1M 6 y`er
ADDRESS 61
TELEPHONE
Address ra''�.'d f Occupant4,I, n l
yo,—
Floor Apartme t No. No. of Occupants
No.of Habitable Rooms_No.Sleeping Rooms 2—
No.dwelling or rooming units No.Stories
Name and address of owner j L.
Remarks Reg. Vio.
YARD Out Bld s.: Fences:
Garbage and Rubbish
Containers:
Drainage
Infestation Rats or other:
STRUCTURE EXT. Steps,Stairs, Porches:
D ress:and Obst'n.:
❑ B ❑ F ❑ M oors,Windows:
Gutters, Drains:
Walls:
Foundation:
Chimney:
BASEMENT Gen.Sanitation:
Dampness:
Stairs:
Li htin :
STRUCTURE INT. Hall,Stairway:
Obst'n.:
Hall, Floor,Wall,Ceiling:
Hall Lighting:
Hall Windows:
HEATING Chimneys:
Central ❑ Y ❑ N Equip. Repair
TYPE: Stacks, Flues,Vents:
PLUMBING: Su ply Line:
❑ MS ❑ ST ❑ P Waste Line:
H.W.Tanks Safety and Vent(s)
ELECTRICAL Panels, Meters,Cir.:
❑ 110 ❑ 220 Fusin ,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.:
Stacks, Flues,Vents,Safeties:
Kitchen Facilities Sink Itik •�
Stove n b
Bathing,Toilet Facil. Vent., Plumb., anit'n.: e4cct rA t1tj&n N
Wash Basin,Shower or Tub:
Infestation Rats, Mice, Roaches or Other:
Egress Dual and Obst'n:
General Building Posted
Locks on Doors:
ONE OR MORE OF THE VIOLATIONS CHECKED ABOVE IS A CONDITION WHICH
MAY MATERIALLY IMPAIR THE HEALTH OR SAFETY AND WELL-BEING OF THE
OCCUPANT AS DETERMINED BY 105CMR 410.750 OF THE CODE OR THE
AUTHORIZED INSPECTOR. (See Over)
"THIS INSPECTION REPORT IS SIGNED AND CERTIFIED UNDER THE PAINS AND
PENALTIES OF PERJURY."
INSPECTORG TITLE
DATE 2 TIME � P.M.
A.M.
THE NEXT SCHEDULED REINSPECTION P.M.
L
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 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.
f
TOWN OF BARNSTABLE
LOCATION
SEWAGE # '
VILLAGE /aj S ASSESSOR'S MAP& LOT
1 n �
INSTALLER'S NAME&PHONE N0. �o
SEPTIC TANK CAPACITY
I. LE
ACHING FACILITY: ( pe) _ S!r��'/�n.gj�,— _(size)
NO.OF BEDROOMS
I BUILDER OR OWNE
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 feet of leaching facility) Feet
I Furnished'by
A3 _
o
o _
t
4 TOWN-OF BARNSTABLE- �
r LOCATION r) SEWAGE #
VILLAGE ��i'1✓1/S ' ' ASSESSOR'S MAP &LOT
INSTALLER'S NAME&PH01NE,NO. 0 f4+
SEPTIC TANK CAPACITY
LEACHING FACILITY:j( pe) 5_19Z6.idAAS __ (size)
NO.OF BEDROOMS
BUILDER OR OWNE
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 feet of leaching facility) Feet
Furnished by
6 '
-y
f:
No. 26co 4 �L . �:� V Fee Sri+—�
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS
01pprication for �Digonl *pg;tem Construction Permit
Application for a Permit to Construct( )Repair( )Upgrade( V�Abandon( ) O Complete System VIndividual Components
Location Address or Lot No. /—3 f r-7,wv v-- Owner's Name,Address and Tel.No.
Assessor's Map/Parcel
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
�n� p �c����i►c�
I S 6o is sT, �v�..fti tiS
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 yb gallons per day. Calculated daily flow L� gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank <L[fit 5T f Type of S.A.S.6 �.-
Description of Soil
Nature of Repairs or Alterations(Answer when applicable) Q -e v A;
(_'T r c�,-y C& k 510,e Ow V -t/(f<<v
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 issued ealth.
Signed Date
Application Approved by Date Z-Z—0'0
Application Disapproved for the following reasons
Permit No. y Date Issued ;2 7
No. �6 —p Fee �
'��"' '' � �
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLES MASSACHUSETTS
Zipplicatiou for Migpogar bpgtem Cons&uctiou Permit
Application for a Permit to Construct( )Repair( )Upgrade( VI�Abandon( ) ❑Complete System RrIndividual Components
Location Address or Lot No. !--3 t (-c,(ccV-- $W Owner's Name,Address and Tel.No.
1� .t�� aaS Vir
assessor's Map/Parcele.} ev
Installer's Name,Address,and
-Tel.No. Designer's Name,Address and Tel.No.
1 S 100 tS 5 T, � c.WL go 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 1_/GO gallons per day. Calculated daily flow ��L�� gallons.
=Plan Date Number of sheets Revision Date
Title
M Size of Septic Tank tit S'1 r c r,„_J Type of S.A.S. t c Cc, nc,c 's Zwj=t
Description'of Soil
Nature of Repairs or Alterations(Answer when applicable) -4-Ot-cam, io-1 �-�O°,c" �d L) (L V1 C_Yk/7
(.__�(C�` C,1�—
Cx•/ <(1 t .J \C-ye 0 ' 'S -f /Cf1, ci LyEr/
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-iss eddy this health._ \\
Signed Date (9-C�
Application Approved by Date Z--ZIry If
Application Disapproved for the following reasons
Permit No. 9P ' Z_ Date Issued
---------------------------------------
THE COMMONWEALTH OF MASSACHUSETTS
2 2 �G� BARNSTABLE, MASSACHUSETTS
Certificate of Compliance ,
THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( )Repaired( )Upgraded
Abandoned( )by lb� `C)-G n P 5 E- C .
at 1 ••- 31, �A,r F,wna r- has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No. ::�Wd'-Co dated
Installer Designer
/
The issuance of this permit shaJ�1Pnot be construed as a guarantee that the syste w/m f kill function as designed.
Date r �� Inspector T 't ., d7 �1/"1
g
— — �� -------------------------------
Fee
THE COMMONWEALTH OF MASSACHUSETTS
N PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSETTS
Migogaf 6pgtem Congtruction Permit
Permission is hereby granted to Construct( )Re air( )Upgrade(Abandon( )
System located at EEO
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 ofMthiet.
Date: Z/2-/ideno Approved by
1l6i99
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, __ i Hereby certify that the application for disposal works
construction perrnit sided by me dated ponce Wing the
property located at meets all of the
following criteria: WWAI
(, The failed system is connected to a residential dwelling only. There are no commercial or business
uses associated with the dwelling.
The soil is cl--sired as CLASS (and tie percolation rate is less than or equal to 5 minutes per inch.
01�711ere are no weulands within, (00 :mot of u,e proposed septic system
There are no private ,yells ,.r-it_,in 1-50 feat of the orcocsed septic system
There is no increase in flow and!cr cH=- ge in use proposed
ere are no variances requested or needed.
The bottom of the proposed lenclung facility Mll not he !ecated less than five feet above the
ma..-amum adjusted groundwater table elevation. [Adjust the groundwater table using the Frimptor
/1f,.he
od when appli=blel
S.A.S. :yill be located azch 250 fee;of any,,e(ge=ed xeulands, the bottom of the proposed
leaching facility Will not 6e !ocated less than founeen(1-1) fee; above the ma-ximum adjusted
Uou.ndwater table e!cvabon.
Please complete the following:
A) Top of Ground Surface Elevation (using GiS informauon)
. �-7 6` Iy of � 3 B) G.`,V. Ele•fauon -the NL-�X High G.W. Adjustme4l ` � = r 3
DCFTERENCE BETWEEN a and 3 Ll
SIGNED : DATE:
(Sketch proposed plan of system on back].
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US Postal Service
Receipt for Certified Mail
No Insurance Coverage Provided.
Do not use for International Mail See reverse
Sent to r -
RnWm r
Post /te, 1 e
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Postage $
Certified Fee
Special Delivery Fee .
Restricted Delivery Fee
N
Return Receipt Showing to
Whom&Date Delivered
a Ret im Receipt Showing to Whom,
Q Date,&Addressee's Address
o TOTAL Postage&Fees $
Postmark or Date _ 7
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07
a
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 y
window or hand it to your rural carrier(no extra charge). 1,Q)
2. If you do not want this receipt postmarked,stick the gummed stub to the right of the Q)
f return address of the article,date,detach,and retain the receipt,and mail the article.
u)
r 3. If you want a return receipt,write the certified mail number and your name and address
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
f RETURN RECEIPT REQUESTED adjacent to the number. a
4. If you want delivery restricted to the addressee, or to an authorized agent of the O
O
addressee,endorse RESTRICTED DELIVERY on the front of the article. CO
5. Enter fees for the services requested in the appropriate spaces on the front of this E
receipt. If return receipt is requested,check the applicable blocks in item 1 of Form 3811. '?`-
6. Save this receipt and present it if you make an inquiry. 102595-97-8-0145 ' a
.� Town of Barnstable
aniws�r"M
Department of Health, Safety, and Environmental Services
A�� Public Health Division
367 Main Street, Hyannis MA 02601
Office: 508-862-4644 Thomas A.McKean,RS,CHO
FAX: 508-790-6304 Director of Public Health
TO: MR. ERIC J. WINER DATE: JAN. 20, 2000
P O BOX 741
SOUTH YARMOUTH, MA. 02664
ORDER TO COMPLY WITH 310 CMR 15.00, THE STATE ENVIRONMENTAL CODE,
TITLE 5.
The septic system owned by you located at 1 HIRAMAR ROAD was inspected on 01/22/97 by
MICHAEL DEDECKO a Massachusetts licensed septic inspector.
The inspection of your septic system showed that your system has failed under the guidelines of
1995 TITLE 5 (310 CMR 15.00) due to the following:
BACKUP OF SEWAGE INTO FACILITY OR SYSTEM COMPONENT DUE TO AN
OVERLOADED CLOGGED SAS OR CESSPOOL.
The above system, according to our records has been in a failed state for more than two years.
Therefore, you are directed to hire a licensed Town of Barnstable septic system installer to sketch
a proposed system that will bring the septic system into compliance with 310 CMR 15.00, The
State Environmental Code, Title 5 within(14) fourteen days of receipt of this notice.
The septic system must be brought into compliance within (30) thirty days of your receipt of this
directive.
You are also directed to maintain the system by hiring a licensed septage hauler to pump the septic
system to prevent discharge of sewage or effluent into buildings, onto the surface of the ground, or
into surface waters.
Any person aggrieved by any order issued by the local approval authority may appeal to any court
of competent jurisdiction as provided for by the laws of the Commonwealth.
PER ORDER OF THE BOARD OF HEALTH
Thomas A. McKean, R.S., C.H.O.
Agent of the Board of Health
Town of Barnstable
q:hdm�slnWud2y.ex
UNITED STATES POSTAL SERVICE First-Class Mail
—___.--Pq§.ta &Fees-Paid
t
0
P m
7
0 Print yourui#nmie, addrb s, and ZlPxCode-in-this'
!"blic If8alth DIV18100,171 u
,.Own of Barnstable
�p 0. BOX 534
*anflik Massaftsells,02601,
d SENDER:
V ■complete items 1 andfor2 for additional services. I also wish to receive the
w ■Complete items 3,4a,and 4b. following services(for an
■Print your name and address on the reverse of this form so that we can return this extra fee):
card to you. ai
Y ■Attach this forth to the front of the mailpieoe,or on the back if space does not 1. ❑ Addressee's Address
I permit.
d ■Write'Retum Receipt Requested'on the mailpiece below the article number. 2. ❑ Restricted Delivery N
« ■The Return Receipt will show to whom the article was delivered and the date
c delivered. Consult postmaster for fee.
d3.Article Addressed to: 4a.Article Number o
4b.Service Type
E
❑ Registered Certified
Im
N v ' � / ❑ Express Mail ❑ Insured -
G ❑ Return Rei di [3 COD D
� 7.Date of 61rry.
�
o
0 5.Received By: (Print Name) 8.Addressee Addir s(bf►y i fequeste
W and fee l id) _
o
P ' Receipt
f
October 11, 1996
Cathy Mason
1 Flax Street
Dennis, MA 02638
NOTICE TO ABATE VIOLATIONS OF 105 CMR 410.00, STATE SANITARY
CODE II, MINIMUM STANDARDS OF FITNESS FOR HUMAN HABITATION
AND THE TOWN OF BARNSTABLE RENTAL ORDINANCE,ARTICLE 51
The property owned by you located at 3 Hiramar Road, Hyannis was inspected on
October 8, 1996 by Christina Kuchinski, R.S. Health Inspector for the Town of
Barnstable because of a complaint. The following violations of the Town of Barnstable
Rental Ordinance Article 51 and the Sanitary Code II were observed:
PJ410.500: There was a large hole at the back of the left most cabinet in the kitchen.
The plumbing for the bathtub could be seen through this hole.
410.351: - The ventilation fan in the bathroom was not functioning.
dO�410.552: The front entrance storm foor did not have a self-closing device.
410.351: The right rear gas burner of the kitchen stove was only lighting half way.
Ci0.351 There was a puddle of water on the bottom inside surface of the
refrigerator, beneath the vegetable crisper. The water was flowing from
the puddle,through the door gasket and onto the floor.
410.504(C): The bathroom wall and tub edge did not form a water tight joint as there
was a large gap between the tub edge and the back wall.
410.550: The dwelling unit was infested with cockroaches. All pesticides used
within the interior of a dwelling shall be applied by a certified pest control
applicator.
v wet (� a
i
410.500: The wall and ceiling in the left rear corner of the master bedroom were
water damaged and growing mildew.
You are directed to correct the remaining above listed violations within seven (7)
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, this violation
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.
You are also subject to non criminal citations of$40.00 for the first violation and $15.00
for each additional violation. Tickets will be issued daily until the violations are
corrected.
PER ORDER OF THE BOARD OF HEALTH
Thomas A. McKean
Director of Public Health
cc: Beina Khawani
Z 948 659 926
Receipt for
` Certified Mail
No Insurance Coverage Provided
is o not use for International Mail
(See Reverse)
in Sent to
t Suet and
A
P.O., rid ZIP Code,
Go 11MtaTe
M
E Certified Fee
O �
U Special Delivery Fee
LIL �FRes�r��IctgdiDelXGryyfE�e
�e umt ecelgt�,,owlr�g
to Whom&Date Delivered
Return Receipt Showing to Whom,
Date,and Addressee's Address
TOTAL Postage
&Fees
Postmark or Date
i
I
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). _
S
2. If you do not want this receipt postmarked,stick the gummed stub to the right of the return rn
address of the article,date,detach and retain the receipt,and mail the article.
t
3. If you want a return receipt,write the certified mail number and your name and address 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 RETURN RECEIPT
REQUESTED adjacent to the number. C
4. If you want delivery restricted to the addressee,or to an authorized agent of the addressee, M
endorse RESTRICTED DELIVERY on the front of the article. 9
0
5. Enter fees for the services requested in the appropriate spaces on the front of this receipt.If t1
return receipt is requested,check the applicable blocks in item 1 of Form 3811. d
6. Save this receipt and present it if you make inquiry. 105603.93:B-021e
Town of Barnstable
Health Department
EPA& 367 Main Street, Hyannis, MA 02601
163p
Office 508-790-6265 Thomas A. McKean
FAX 508-775-3344 Director of Public Health
October 11, 1996
Cathy Mason
1 Flax Street
Dennis, MA 02638
NOTICE TO ABATE VIOLATIONS OF 105 CMR 410.00, STATE SANITARY
CODE II MINIMUM STANDARDS OF FITNESS FOR HUMAN HABITATION
AND THE TOWN OF BARNSTABLE RENTAL ORDINANCE, ARTICLE 51
The property owned by you located at 3 Hiramar Road, Hyannis was inspected on
October 8, 1996 by Christina Kuchinski, R.S. Health Inspector for the Town of Barnstable
because of a complaint. The following violations of the Town of Barnstable Rental
Ordinance Article 51 and the Sanitary Code II were observed:
410.500: There was a large hole at the back of the left most cabinet in the kitchen.
The plumbing for the bathtub could be seen through this hole.
410.351: The ventilation fan in the bathroom was not functioning.
410.552: The front entrance storm foor did not have a self-closing device.
410.351: The right rear gas burner of the kitchen stove was only lighting half way.
410.351: There was a puddle of water on the bottom inside surface of the
refrigerator, beneath the vegetable crisper. The water was flowing from
the puddle, through the door gasket and onto the floor.
410.504 C : The bathroom wall and tub edge did not form a water tight joint as there
was a large gap between the tub edge and the back wall.
410.550: The dwelling unit was infested with cockroaches. All pesticides used
within the interior of a dwelling shall be applied by a certified pest control
applicator.
410.500: The wall and ceiling in the left rear corner of the master bedroom were
water damaged and growing mildew.
You are directed to correct the remaining above listed violations within seven (7)
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, this violation
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.
You are also subject to non criminal citations of$40.00 for the first violation and $15.00
for each additional violation. Tickets will be issued daily until the violations are corrected.
PER ORDER OF TH BOARD OF HEALTH
mas A. McKean
Director of Public Health
cc: Beina Khawani
t/ n
N I
NOTICE TO ABATE VIOLATIONS OF 105 CMR 410,00, STATE SANITARY
CODE II,-MINIMUM STANDARDS OF FITNESS FOR HUMAN HABITATION
AND THE TOWN OF BARNSTABLE RENTAL ORDINANCE,ARTICLE 51
The property owned by you located at 3 1 !�i was inspected on
(ISM by CMe( Health Agent for the Town of Barnstable because of a
complaint. The following violations of the Town of Barnstable Rental Ordinance
Article 51 and the Sanitary Code II were observed:
l av Gw fp W-e
C6-r /11 q4,-e � Ce
6a,4-h4016 6'0." eLa� no
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y lO,351
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u ar ire ct corre a vi ion o in 4 h rs f re ipt f t
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You Are ilft directed to correct the remaining above listed violations within seven
(7) days of receipt of this notice.
You may request a hearing if written petition requesting same is received by the Board of
I Iealth within seven (7) clays 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.
You are also subject to non criminal citations of$40.00 for the first violation and $15.00
for each additional violation. Tickets will be issued daily until the violations are corrected.
Enclosed are citation numbers due to violations
observed on
PER ORDER OF THE BOARD OF HEALTH
Thomas A. McKean
Director of Public Health
Town of Barnstable
FORM30 Hoess&WARREN,INC.NOV.1979-1983 THE COMMONWEALTH OF MASSACHUSETTS 1
BOARD OF HEALTH
' CITY/TOWN AZ /
W )
e DEPARTMEN
2 ?l 4-?�16r 1
v, syey'y ADDRESS
TE1,EPHONE
Address Occupant
Floor Apartment No: No.of Occupants
No.of Habitable Rooms No.Sleeping Rooms/
No.dwelling or rooming units No.Stories
Name and address f owner
a
Remarks Reg. Via.
YARD Out Bld s.: Fences:
Garbage and Rubbish
Containers:
Drainage
Infestation Rats or other:
STRUCTURE EXT. Steps,Stairs,Porches: Oki
Dual Egress:and Obst'n.: J/ao - ,,le�
❑ B ❑ F ❑ M Doors,Windows: 6(YL,2z
.efx-2;_
Roof ,f
Gutters, Drains:
Walls: U&Wk 64-cQ u t t4 vv,
Foundation:
Chimney: &&uY6-4t01'-' -
BASEMENT Gen.Sanitation: w r' !
Dampness: r'
Stairs:
Lighting:
STRUCTURE INT. Hall,Stairway:
Obst'n.:
Hall, Floor,Wall,Ceiling:
Hall Lighting:
Hall Windows: i
HEATING Chimneys:
Central ❑Y ❑ N Equip. Repair
TYPE: Stacks, Flues,Vents:
PLUMBING: Supply Line: t
❑ 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 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 /
Not Water Facil. Sup.Ten.,Gas,Oil, Elect.:
Stacks,Flues,Vents,Safeties:
Kitchen Facilities Sink f
Stove w�t%t U
Bathing,Toilet Facil. Vent., Plumb.,Sanit'n.: � ��.
Wash Basin,Shower or Tub: " i
Infestation Rats,Mice Roaches or Other:
Egress Dual and Obst'n:
General Buildina Posted
Locks on Doors:
ONE OR MORE OF THE VIOLATIONS CHECKED ABOVE IS A CONDITION WHICH
MAY MATERIALLY IMPAIR THE HEALTH OR SAFETY AND WELL-BEING OF THE
OCCUPANT AS DETERMINED BY 105CMR 410.750 OF THE CODE OR THE
,. AUTHORIZED INSPECTOR.(See Over)
"THIS INSPECTION REPORT IS SIGNED AND CERTIFIED UNDER THE PAINS AND
PENALTIES OF PERJURY."
INSPECTOR 01A(44y `14 `TITLE
� A.
DATE 0 k 96 TIME
� M:
A.M.
THE NEXT SCHEDULED REINSPECTION P.M.
r.
410.750: Conditions Deemed to Endanger or Impair Health or Safety c•
The following conditions, when found to exist in residential premises,
shall be deemed conditions which may endanger or impair the health, or safety
and well-being of a person or persons occupying the premises. This listing
is composed of these items which are deemed to always have the potential to
endanger or materially impair the health or safety, and well-being of the
occupants or the public. Because Chapter II, 105 CMR 410.000 through 410.499
state minimum requirements of fitness for human habitation, any violation has
the potential to fall within this category in any given situation but may not
do so in every case and therefore cannot be included in this listing. Failure
to include shall in no way be construed as.a determination that other
violations may not be found to fall within this category. Nor shall failure
to include affect the duty of the local health official to order repair or
correction of the violation(s) pursuant to 410 CMR 410.830 through 410.833
nor shall it affect the legal obligation of the person to whom the order is
issued to comply with such-order.
(A) Failure to provide a supply of water sufficient in quantity, pressure
and temperature, both hot and cold, to meet the ordinary needs of the occupant
in accordance with 105 CMR 410.180 and 410.190 for a period of 24 hours or
longer.
(B) Failure to provide heat as required by 105 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) Shut-off and/or failure to restore electricity or gas.
(D) Failure to supply the electrical facilities required by 105 CMR 410.250(B);
410.251(A), 410.253(A), 410.253(B) and the lighting in common area required
by 105 CMR 410.254.
(E) Failure to provide a safe supply of water.
(F) Failure to provide a toilet and maintain a sewage system in operable
condition as required by 105 CMR 410.150(A)(1) and 410.300.
(G) Failure to provide adequate exits, or the obstruction of any exit,
passageway or common area caused by an object, including garbage or trash,
which prevents egress in case of an emergency 105 CMR 410.450 and 410.451.
(H) Failure to comply with the security requirements of 105 CMR 4111.480(D).
(I) Failure to comply with any provisions of 105 CMR 410.600 through 410.602
'wbich results in any accumulation of garbage, rubbish, filth or other causes
of sickness which may provide a food source or harborage for rodents, insects
or other pests or otherwise contribute to accidents or to the creation or
- spread of disease.
(J) The presence of lead-based paint on a dwelling or dwelling unit in
violation of the Massachusetts Department of Public Health Regualtions for
Lead Poisoning Prevention and Control 105 CMR 460.000.
(K) Roof, foundation, or other structural defects that may expose the
occupant or anyone else to fire, burns, shock, accident or other dangers or
impairment to health or dafety.
(L) Failure to install electrical, plumbing, heating and gas-burning
facilities in accordance with accepted plumbing, heating, gas-fitting and
electrical wiring standards or failure to maintain such facilities as
are required by 105 CMR 410.351 and 410.352 so as to expose the occupant
or anyone else to fire, burns, shock, accident or other danger or impairment
to health or safety.
(M) Any of the following conditions which remain uncorrected for a period
of five or more days following- the notice to or knowledge of the owner
of said condition or conditions:
(1) lack of a kitchen sink of sufficient size and capacity for
washing dishes and kitchen utensils or lack of a stove and oven
or any defect that renders either operable.
(2) failure to provide a washbasin and a shower or bathtub as required
in 105 CMR 410.150(A)(2) and 410.150(A)(3) and any defect which
renders them inoperable.
(3) any defect in the electrical, plumbing, or heating system which makes
such system or any part thereof in violation of generally accepted
plumbing heating,, gas-fitting, or electrical wiring standards
that do not create an immediate hazard.
W, failure to maintain a safe handrail or protective railing for every
stairway, porch balcony, roof or similar place as required by
105 CMR 410.503(A) and 410.503(B).
(5) failure to eliminate rodents, cockroaches, insect infestations and
other pests as required by 105 CMR 410.550.
(N) Amy other violation of Chapter II not enumerated in 105 CMR 410.750(A)
through (M) shall be deemed to be a condition which may endanger or materially
impair the health or safety and well-being of an occupant upon the failure of
the owner to remedy said condition within the time so ordered by the board
of health.
LOCATION SEWAGE PERMIT NO.
1 & 3 Duplex Quaker Village 82-583
VILLAGE 3 Hirimar Road
Hyannis
INSTALLER'S NAME D ADDRESS
Robert B. Our
6 U I L D E R OR OWNER
Quaker Village - 3 Hirimar Road, Hyannis
.DA.TE PERMIT ISSUED 10-6-82
DATE COMPLIANCE ISSUED 10-8-8.2
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No.XT Z-583 ..: �"F 2g.-.3......
.....................
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
...d� :ll....: :..:o F.......... - �4a31G.................................
AvOiration' for Bisposal Workii Tnnstrnrtion Frrmit
Application is hereby made for a Permit to Construct ( ) or Repair an Individual Sewage Disposal
. System at
i� ...............••-•-•--•------....._......... ......------•------•-------.................--�t-----------------•---------.....---......----•-
loca-tion1�
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.It 2.1�1dd. � � .. -.....----
W �r.+ram=e3•• i.. =... .. ......mt...1:1C--ew ess � w ^rL_
Installer ... ......_.....
� Address
UType of Building '' Size Lot............................Sq. feet
Dwelling—No. of Bedroom.............................................Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
dOther fix es ----•••••-------••-•-••-•-------•--•••••---•---..............................................................
W Design Flow.............. ................... per person per day. Total daily flow................
Pl-------------------------gallons.
WSeptic Tank—Liquid capacity. __..gallons Length................ Width................ Diameter---------------- Depth................
x Disposal Trench—No..................... Width....I............... Total Length............. Total leaching area-------------------sq. ft.
Seepage Pit No-------------(------- Diameter.....1._I......... Depth below inlet......(P........_. Total leaching area_. .....sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by.................................
a ----------------•---.....----•--...------ Date...........-............................
Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................
fX4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water...._...................
py •---•-•----•---------...•-•-----------•--•--••-------•--••-•-•-•----•••-••--••--•-••-•------•-------------------•-••-•-----••---•---••• -------
•.........
O Description of Soil.........................................................................................................................................................•----••-•----
V -•.............••••••. ......................................o......................................................................------••••----•-••••-••-----------••--••••----••......••••-•..-•--
W
V Nature of Repairs or Alterations—Answer when applicablt�__ _.ew 5i ^ �
..
firx !-......w ?. °! E...1.,wb, .....................•.............
A `eement
The undersigned agrees to install the afored cribed Individual ew e Disposal System in accordance with
the provisions of TITLE5 of the State Sanitary ode—The under n fur zer agrees not to place the system in
operation until a Certificate of Compliance has be ssued by e b f health.,
S ed--••�..... ..... ....... .....••• ---------._....----�••••...
� llot-
Application Approved By ••••• -----_ ... ......... •• . •... ............................... ........
Da e
Application Disapproved for the f ollowi easons:.....................-...........................................................................................
- -------------•••-----•••--•-••••-•-•---...-••-----•-•---•-•••---------•••--------------••-------•--- -•-----••-•---
Date
PermitNo......................................................... Issued..................- --• ......................... f
Datoe
T
612-585
No................_....... t xi, IB..............................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
...........................................O F..........--.--.... ..................---.....................-----•---•-------•----._--•
Appliration for Dhipviial Works Tonstrurtinn Frrmit
Application is hereby made for a Permit to Construct ( ) or Repair X an Individual Sewage Disposal
System at
------------------- ...................................................... _.....----...--•---------.............--------.._............••---..................-------------•
Location.-Address ,{ , or L No.
' .. �. ..... Lot i---�
-Ovine Address
k(C
Installer Address
QType of Building Size Lot............................Sq. feet
V Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
QIOther fixtures ---------------------•--•--------------------------------•-•-•------•••---•--•----------••-••--•-•-••-•...•.;:---;-----------.------------------.
Q
w Design Flow.....-----------�------------.---.y____gallons per person per day. Total daily flow--------------------------------------------gallons.
WSeptic Tank—Liquid capacity.._.......gallons Length________________ Width................ Diameter................ Depth................
x Disposal Trench—No. .................... Width.................... Total Length.........,_. .....
Total leaching area-----__-...........sq. ft.
Seepage Pit No............. Diameter.....1_.-!-......... Depth below inlet...../ :_:::.... Total leaching area.... %2 ......sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
aPercolation Test Results Performed by.......................................................................... Date........................................
,4 Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water-----------_............
fL Test Pit No. 2................minutes per inch Depth of Test Pit..............._.... Depth to ground water........................
•............ -----•------------------------------ ---••------• ...............................
0 Description of Soil................................... ---------------• --------------------------------------------- .........................-----------•--------------------
x
w
--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
U Nature of Repairs or Alterations—Answer when applicable..----'--'. .` ' r d
----------------- ---------------------------•------
-------•••-•--•---•••-••••••-••-•--•.......•••-•------•---••-•-•--•......----•-•-•-••------_-•----•---•-......-•---......•-•-------•-•- ..........................................................
Agreement: -
The undersigned agrees to install the aforedescribed Individual.,,Sewage Disposal System in accordance with
the provisions of TITIE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the board of health,
Signed
j ��jd!����2 ate
Application Approved By...................................�..
Date
Application Disapproved for the following-reasons:--••--.........--•••---•••--••-•----------------------••------------------------------•--•••--•---•-•...._------
.......................:......•---------------------------......--------------------•---•----------•--'--------........-------•--•------------------------------------••-----•-------------.........
Date
Permit.No.....................................•-•----•----........ Issued.......................................................
Date
T14E COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
..........................................OF.....................................................................................
Trrtif iratr of Tuntpliatta
THIS IS TQ-�TIb' That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
by ................ ..-•--•-..... '.----- .......----------•--•-----•---------------------------•--------.......----------....-----............---••-------......--.....
S+.,5-
Installer
at................................................................... .__............••-•--•--•-•--.._...••---•--•--------------------•-•----•-----•-•----------••--........_......................•...
has been installed in accordance with the provisions of TITL4 0 of VgState Sanitary Code as described in the
application for Disposal Works Construction Permit No......................................... dated-...............................................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTR ® AS A GUARANTEE THAT THE
SYSTEM W L NC,TION SATISFACTORY.
DATE.lO �............... Inspector
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
I �
_J 0' 1...................OF.........:
No........:..... .... FEE.,?/
14sp asa1 Works Tonotnutwit prrutit
Permission is hereby granted.. ''_0'— ._....'_....._..C.4)'_.__._ O_:___..�1. .................... .....................................
to Construct ( ) or Repair (><) an Individual Sewage Disposal System
Street
as shown on the application for Disposal Works Construction Permit No.__..-.•............. ated..........................................
...--� - --- --------------------------------------------------
-- •----•-- Board of Health
DATE------------------ 17. Viz.
FORM 1255 A. M. SULKIN, INC., BOSTON
UNITED STATES POSTAL SERVICE First-Class Mail
Postage&Fees Paid
USPS
s Permit No.G-10
Print your name, address, and ZIP Code in this box •
lth �. '
Board of hea
Town of Bamstabl0
P.O.Box 534
nts,Maf;sachusetts 02601
l
I ui SENDER: 1 also wish to receive the
1 0 ■Complete items t and/or 2 for additional services.
0 ■Complete items 3,4a,and 4b. following services(for an
H ■Print your name and address on the reverse of this form so that we can return this extra fee): `
I card to you. ai
I ■Attach this form to the front of the mailpiece,or on the back if space does not 1. ❑ Addressee's Address
4) permit.
d ■Write'Return Receipt Requested'on the mailpiece below the article number. 2. ❑ Restricted Delivery to
I Y ■The Return Receipt will show to whom the article was delivered and the date a
I c delivered. Consult postmaster for fee.
0
v 3.Article Addressed to: 4a.Article Number a0i
Id r , c
I S /-� t 4b.Service Type w
❑ Registered 10 Certified °C
I in (V% ❑ Ex ress M i 5
p (}�.�5� Insured .y
¢ ❑ Return Ret�f'dr'Merch' ise ❑ COD
I< ✓ 7.Date of +elite ,
0
I m 5.Received By:(Print Name) 8.Addressees ddress nLy�idrequested
W and fee is�paid t
W t—
g 6.Signature: (Addressee or Agent)
XCan I
`YU
H PS Form 3811, D cember 1994 Domestic Return Receipt