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HomeMy WebLinkAbout0025 VALLEY BROOK ROAD �• � � ;. � � �� � o �_ f . � _ _ :, e ... _ 4 ..: � , �� . �. ., .. ... �- � 1 .' .: .,_ ., .. �, Y .. ... .. �:. ,' � .: fl ., � .. .. n . .. .. � . ,. .. �. i. ,. ,�. �� � � .. .. y -, � .. �. - � ., ..C ..: .. -. .. �. .. .. � _ , r� .. i. - - .,. .. .. y .. i. t. .,. .. - �. � r ... sF � ,� o �,. ��. Y .. ,. .. a .. .. �. ., � '. ,. '. � � .. .. .� - �. a .. .. 50 .. .� ... 1. .. ., �. _ - _ � .. � - - :. i a e. .� _ c � � -� �i ,. y "� UO GAtzgnG.S (�W s l 10 � 3 • `33t7 (s•P.U. ��� , �E-Q'iLl G TL�.i.t K � 330� ISO % • Q.�i�7 6.P 0. USE- 1000 6AL-. �ISPOSAi. PIT - I�SE loco <GAI,-. ,ty>GWALL AzaA J / lSp 5F= • • A 2.S • 3 7� G.P.D. �p'I✓�� / /� S$.5�� 8crt'r'nm �¢�. 5T=. i /I•Z'�.$�7 n 5D s+3'. K t .o % S.4> L -C�ESIGN • :5 G.P oT,s k Tt>TA 1_ -Dat L-( Flaw z PMCOLQTIOLJ O&TE : )"IQ SMI lJ' OIZ LESFs. � i35t I /�ND•�a.•�^ �l ALAN PIT. 1131•z FICHARD � W. .� 1 Z BAXTU9 ini 4` i ► I No.24048 F . T EF'��`` ((� M M ��lS1' Pb'p4. i 0 N M. n s ti� TEST P 121'I F'G= B -lop r•�o •4'�,•-� 31 82 4 ELM 38 � LoA d , I 000 5�9501L. �Ppfs �, IW. 6.4L. 3G• .r 3� 4v -Box 15•9 T�icc �z loco 35.2 i►�v. Iw. 't. Go 513 GAL.. 3S.d: 35 G C A401 LAN C,,�a ll►3t.. FIT - . WAfL/CD STOwr� 29�2 SAIJ� CEQTIFIED pLC) PL.�4fr.1 P20F'1 L_ LoCATI0" C�\/ILLS �Lt • ' 13 LJo Scla,t-�- �c1�1,C IL (oo bATC— G /S f 82 G 6 lz-r I F Y T;4 A-r T I-1 I-c�IJI��QT101, S UorcA�J 41EI'tool,l GbN>PLC!a �l/1TI-1 TW : '51DeLl I AuD �sert..ACIC �C-4u,ceMcuTS OF TI-►C— '�"T -TO VJ Q Or-- L3Q>`tz�ST L L� L.��, GvQ7 i2CGlS tt-FLED t�NG 5uev�=`(Oe� '(l-1 I S C7 L A►-1 le, U OT e-A►S r--v vat A" OSTE�V1l.l.G o titAS��� lWSrecJ.v�c_w;' �,Uc_v�_�{ T►�C: c�1=c,�("�, ,I•lowLU APPL-IGAI-,1T I•k�t' E'�C: a-:,Cn r�� 1��'Tc�MI►.11= LOT t_►N�=•� A4m5,> �kUlTt4 ..7. /W jFSewag,q,,P sor's map and lot number ............. ...... . CF THE t0 it number Z 3 2. -49............... SEPTIC SYSTEM �� �♦� . INSTALLED A I�11l�T ®��Ts4LL BHBST�LE, i House number ��'��....:...................; ... ..... ................. aa��9g�ypp���WITH TITLE 5 °os,M6 9. 0� ENVIRMItloW1IlI�T� 'F11 MAI . , ®DE AN . TOWN 'OF . BA:R N�At „ TpORS BUILDING INSPECTOR APPLICATION FOR:.PERMIT TO;....:...;Construct Dwel_.ling .......... ... . ... ... . .................................... TYPE OF CONSTRUCTION ..................W.Q Q d...,fr. le......................................................................................... '....... .�, !.........19-K TO THE INSPECTOR OF .BUILDINGS The undersigned hereby applies for a permit according to the following information:. Location ............Lot 9 Valleybrook Road, Centerville ProposedUse ......SiXlgle...FaTTIilY.... ................:..........................................:........................................ a....................... Zoning District ....ReS.7.dzatlal.......................................Fire -District ......Q.SX1t.-.Q.*.t................................................... Name of Owner .....a11 ith...............................Address ..........Barnstable.............................................. Name of Builder" ....5..IA,7.th........:............:......Address ............Barnstable ........................... Nameof Architect ......................:.................................,.........Address ...................................................... Number of Rooms ..............5..................................................Foundation. . .. ..poUbe.d...C.RX.LGme o................................ Exterior .....clajab.aard..&..w.0...Sh1.7 gle.S...................R.'oofing ........:....�,aphalt..................................................... :.. Floors .......sIa1.1, " ,..tU..;Srlall .. ..................................................Interior . ......:....dr.�fa�.� .�.............;............ ..... 74 Heating ....11a....by 0,il..................................................:.Plumbing ..........2...bathZ.................................................... :.. Fireplace One Approximate Cost 55 ........ •••••••... 000 ..............................:............................................ Definitive•Plan Approved by Planning Board,---________--___-______ `" -----1 9-=---. Area .:.................... Diagram of Lot and Building ;with Dimensions Fee SUBJECT TO APPROVAL OF BOARD OF HEALTH OCCUPANCY PERMITS REQUIRED FOR NEW DWELLINGS 1 hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. .t Name ... .. ......`..''..... ...................... - JAME S K. 0 2420.�..: Permit for .................................... Story �3 Single Famil[y� Dwellin/yy i. •..• ...........................: Y'1••......•............•.•I.......•.....• • yak Lot #9 25 Valle brook Rd' Location ...........................................X................... � . Centerville - �! ...............James...K ...Smith..............:........... Owner ............................................................... r Type of Construction ..Frame..... ................. ` ` ........................... .............................' ................. Plot ..................... Lot4. 4 July ' 1;3, Permit Granted .........................................19 82 �. Date of Inspection ..............................`" Date Comm eted . ... ... :19 t„ 3 ' Assesp- " a .,jr's map and lof number .................................... ..... . � CF 7HE t0� Sewer e-,,Permit number F 2- . 3. ..........� ..... Z EARNSTAIME, i House number ....:.�..........!: •...................:..l........................... 900 ,,"AGIL 6 9. 0 TOWN OF BARNSTABLE BUILDING INSPECTOR APPLICATION FOR PERMIT TO .......... onstruat. . ....Dwelling...... .... ....... ................................................................................ TYPE OF CONSTRUCTION 1€Jn f rd tn!!ne........................................................................................ ......................................... ? ....... ..`. ......19.. 2. y TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following information: Location ............Zot 9 Valleybrook Road, Centerville Proposed Use .......,irq, FaT1i,'i_v Zoning District ...R.FPni ........................................Fire District ......C`k?1 ,-- ? f...................................................... Name of Owner JaMTS Kr �r,Af�?...............................Address l��stable Name of Builder' ..-Tanp.s...K:r Smith.............................Address Barnstable ................ .............. ................................................................ Nameof Architect ..................................................................Address .................................................................................... Number of Rooms �'..................................................Foundation ......:N)Xreff...� r•r t;e ................ ................................................ Exterior ..... ..................Roofing .......... !.nnh t:...................................................... Floors tr�l�l .t n 1-m0l................................................Interior ............t,?nT.Vtf 1:1...................................................... ...............................,:...... Heating .._ ...Plumbing 3 '1`.+-1 A. "*55s000 Fireplace ...OnC........................................................................Approximate Cost .................` ................................................ Definitive Plan Approved by Planning Board ---------------____-----------19________. Area ................`'.,.'..................... Diagram of Lot and Building with Dimensions Fee ... �.., �.................................. SUBJECT TO APPROVAL OF BOARD OF HEALTH Z OCCUPANCY PERMITS REQUIRED FOR NEW DWELLINGS I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. / U t�} Nameli...................r°..'!................. ...................... SMITH, JAMES K. A=1884 No 24207 Permit for 1 ../Story Single Family Dwelling ......................................................... ....... i f .)cation , Lot # 9 25 Valleybrook Rd. ............................................ Centerville ............................................................................... I Owner James K. Smith ................................................................. Type of Construction ..Frame ............................................................................... Plot ............................ Lot ................................ Permit Granted ..July....1.3....................19 82 Date of Inspection ....................................19 Date Completed .......................................19 h .tee. . :TM TOWN OF BARNSTABLE Permit No. __ "4 2 0 7 v �+ �t Building Inspector cash. ru 9 OCCUPANCY PERMIT Bond "No building nor structure shall be erected, and no-land;building or structure shall be If used for a new, different, changed, or enlarged use without a Building Permit therefor first having been obtained from the Building Inspector. No building shall be occupied until a certificate of occupancy has been issued by the Building Inspector." Issued to Address 1 James K. smith (_ 4 Laic. #9,. 25 Vail.eybrook Road, Centerville Wiring Inspector i �.r' _- Inspection date Plumbing lhspectorl. ' f `r Inspection date V Gas Inspector '�- Inspection date C.71 NEngineering Department - Inspection date/6-e7 THIS PERMIT WILL NOT BE VALID, AND THE BUILDING SHALL NOT BE OCCUPIED UNTIL SIGNED BY THE BUILDING INSPECTOR UPON SATISFACTORY COMPLIANCE WITH TOWN REQUIREMENTS. 7 7- Building Inspector `Y f Town.of Barnstable aFthe ram, Regulatory-Services Thomas F. GeHer,Director �} `Building Division + BARNSTABLE, Tom Perry,Building.Commissioner_ m 200 Main,Street, Hyannis,"MA.02601 www.totvn.barnstable.ma.us_ Office: 508-862-4038 �,a508-790-6230 PP '-rovedrR:Fee: r$�5-, Permit#: qS HOME OCCUPATION REGISTRATION Date: Nautc: ?Gu-1 VL LV'% Phone.#: `� '�iN°1Z' 31yA Address: Village 'ftd1'E{ru 1 U4 Nance of 13u5iitess �Iv1�tr� L.�1�1 �Ctn�� ---- — -------- ---- — — ----— ------ -- ---- ------ Type of Business: LC4 V 1 d!�C.ot04 Map/Lot P INTENT: It,is the intent orthis sectic�n to'alloat the residents of the"16 vn of"Iiarnstable to operate a home;occ•upatiou witliin single Family dwellings,subject to the provisions'of:Sec•tion 4-1.4 of the /.oiling orditlance,provided t{iat the activity sliall not be'discernible from outside the dcvelling: there shall be no increase in noise or odor; no casual alteration to the V premises tvlticII Would suggest.atytltiug other'tltat a'residential use;no increase air traffic above normal residential volumes; and no increase in air Or gr6UL kvater 'Pollution. After registration with the Building htspector,a custoniary Monte occupation sltalt•be permitted as of right subject to the following conditions: ` • The activity,is carried on by the perntauent resident of ai single family,residential"(N!elling unit, located within Chat dwelling unit. ; Such use occupies no more that 400 scjuaue feet of space, • There are no externad�dte.rations to the.dwelling which.are not customary,1(1 residential buildings,And there is no outside evidence of such use. No traffic will he generated in excess of normal residential volumes. • the use does not.involve t Ic.production of offensive nM smoke, dust or other particular matter, odors,electrical disturbance, heat,glare,humidity or other objectionable effects. There is no storage,or use of toxic or hazardous MatCri'As,or flammable or explosive materials, in excess of nomia.1 ltouseltold gtiantities. •' Any need for parking generated by such use shall be met on the saitae lot contaiuiiig the Customary Home 0ccupatioti,and not«6tltin the required front yard. • `I'liere is no exterior storage oi•display of niatetials or equipment. There are.no commercial vehicles related to die Cus(ontaty Home C)ccupation,ofhe-than oiie Van or one pick-up,truck not.to exceed`p e ton c tpacity,and one tiiiiler not to e�cecd'20 feet in lerigili'and not to exceed 4 tires,pa•ked on the same lot containing the Customary Honie Occupation. • No sigh shall be displayed indicating the.Cus4omary Hointe Occupation. If the Custommay Home Occultation Is listed or advertised as a business;the street address shall not be . included. • No person shall be employed in the Customary Home'Occ•upatiou Who' is,11ot a perntauent resident of(ate dwelling unit. I, the undersigrie I; taV res and agree chili the above restrictions for lily home cx.cupaticxt f anr'registering. ' APpli(•ant: ' Date:. �J . YOU WISH TO OPEN A BUSINESS? For Your Information: Business certificates (cost$30,0Cjor 4 years). A business certificate ONLY REGISTERS YOUR NAME in town (which you must do by M.G.L.-it does not give you permission to operate.) Business Certificates are available at the Town Clerk's Office, 1"FL., 367 Main Street, Hyannis, MA 02601 (Town Hall) n DATE: I Fill in please: APPLICANT'S YOUR NAME/S: ":4 �' t �" BUSINESS YOUR HOME ADDRESS: F il TELEPHONE. # Home Telephone Number G S& NAME OF CORPORATION: NAME OF NEW BUSINESS - -,(�;�\Vn l,c,�c\s ����� TYPE OF BUSINESS l_����{U.�<, IS THIS A HOME OCCUPATION? ffES 1 NO ADDRESS OF BUSINESS S' S�MAP/pARCEL NUMBER I(�UU` �S Co (Assessing) When starting a new business there are several things you must do in order to be in compliance with the rules and regulations of the Town of Barnstable. This farm is intended to assist you in obtaining the,information you may need. You MUST GO TO 200 Main St. - (corner of Yarmouth - Rd. &Main Street) to make sure you have th e he appropriate permits and licenses required to legally operate your business in this town. : 1. BUILDING COP S .IS 5 ER'S'OFF CE C 'i Y1�bC�.���•�ef,1'he;jcti2r�S��ce �t���r���� hlo•v�r�, This indivic al h s n iriff0, rmit re uirements that pertain to this type of business. �+a^„n;�• >> v��\�`�� •.af ,zed.,.,�kc� Auto ' d Si gna — MUST COMPLY WITH HOME OCCUPATION MMENTSANn REGLII E TO SAL- 7>; 4 n 2. BOARD OF HEALTH This individual has been-infp r ed of the permit requirements that pertain to this type of business., MUST COMPLY WITH ALL �' '-1 ZI I'1/ 0HAZARDOUS MATERIALS REGULATIONS Authorized Signature* COMMENTS: 3. CONSUMER AFFAIRS (LICENSING AUTHORITY) This individual has been informed of the licensing requirements that pertain to this type of business. Authorized Signature* COMMENTS: i TOWN OF BAR Date:+z . NSTASLE TONIC AND HAZARDOUS MATERIALS ON-SITE INVENTORY NAME OF BUSINESS: BUSINESS LOCATION: „y Au ------------ INVENTORY MAILING ADDRESS: � ar TOTAL AMOUNT: TELEPHONE NUMBER: . - ? ���( _ t.3 G� CONTACT PERSON: W1LOA 11.,• ��r EMERGENCY CONTACT TELEPHONE--t14UMBER: TYPE OF BUSINESS: MSDS ON SITE? INFORMATION/RECOMMENDATIONS: Fire District: Waste Transportation Last shipment of hazardous waste: Name of Hauler: Destination:' Waste Product: Licensed?-Yes No NOTE: Under the provisions of Ch. 111,'Section 31, of the General Laws of MA, hazardous material use, storage and disposal of 111 gallons or more a month re wires a license from the Public Health Division. LIST OF TOXIC AND HAZARDOUS MATERIALS The board of health and the Public Health Division have determined that the following products exhibit toxic or hazardous characteristics and must be registered regardless of volume. Observed / Maximum Observed / Maximum Antifreeze (for gasoline or coolant systems) Miscellaneous Corrosive ❑ NEW ❑ USED Cesspool cleaners Automatic transmission fluid Disinfectants Engine and radiator flushes Road salts (Halite) Hydraulic fluid (including brake fluid) Refrigerants Motor Oils Pesticides ❑ NEW ❑ USED (insecticides, herbicides, rodenticides) Gasoline, Jet fuel,Aviation gas Photochemicals (Fixers) Diesel Fuel, kerosene, #2 heating oil ❑ NEW. ❑ USED Miscellaneous petroleum products: grease, Photochemicals (Developer) lubricants, gear oil ❑ NEW ❑ USED Degreasers for engines and metal Printing ink Degreasers for driveways &garages Wood preservatives (creosote) Caulk/Grout Swimming pool chlorine Battery acid(electrolyte)/Batteries Lye or caustic soda Rustproofers Miscellaneous Combustible Car wash detergents. Leather dyes Car waxes and polishes Fertilizers Asphalt& roofing tar PCB's Paints, varnishes, stains, dyes Other chlorinated hydrocarbons, Lacquer thinners (including carbon tetrachloride) — ❑ NEW ❑ USED - Any other products with "poison" labels Paint&varnish removers de lossers (including chloroform, formaldehyde, de, hydrochloric acid, other acids) Miscellaneous. Flammables Other products not listed:which you feel Floor&furniture strippers may be toxic or hazardous (please list): Metal polishes Laundry soil,&stain removers (including bleach) Spot removers &cleaning fluids (dry cleaners) Other cleaning solvents Bug and tar removers Windshield wash WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS Applicant's Signature Staff's Initials I _ DATE: August 12, 2010 TO: Building File " FROM: Robin Anderson, ZEO RE: 25 Valley Brook Rd, Centerville Received a complaint on this date'regarding a lawn business being run out of this property and general overcrowding issues. Drove by on this date at 1:45 PM. Found only two vehicles on site and no activity or evidence of anything other than a single ' family use at this time. `Will monitor. � AM�fi �g ° .-�orJ TOWN OF BARNSTABLE 1911'fiUG 12 PM 12 54- Building Dept. 200 Main St. Hyannis, Ma. Sirs, It might be of inteerest for .the Bui1_ding Inspector to check the validity of 'a permit to rent'25 Valle brook Rdin- Centerville_ , Ma. This house has been o cc uc pied for-at least 'a-'year and half. . Further , ta-LAWN-busine�has--been established t this residential area=. At various times trucks and three or for cars w 11 be parked on the road, randTan acetylene,, torch was-s-een' working:in-the-g-ara-ge If the tenant denies th�i�s,"the condition of the front lawn aC"7the road will show where the cars and trucks have' killed the grass. As I have pointed out, this` is .a non'-commercial area. I hope you will do° something about it. It certainly is not going to get any better. A concerned person in the'area. Barnstable Assessing Search Results Page 1 of 2 Home:Departments:Assessors Division:Property Assessment Search Results " New Search 6 ,; New Interactive Maps» Owner: 2010 Assessed Values: SHIELS,THOMAS L~ET AL 25 VALLEY BROOK ROAD 201U Appraised Value 2010 Assessed Value Past Comparisons Map/Parcel/Parcel Extension' -Building Value: $132,900 $132,900 Year Total Assessed Value 188 /156/ Extra Features: $3,300 $3,300 2009-$304,700 Outbuildings: $0 $0 2008-$348,800 Mailing Address Land Value: $160,000 $160,000 2007-$347,800 j SHIELS,THOMAS L ET AL 2006-$298,400 2010 Totals $296,200 $296,200 ' 145 OCEAN AVE#516 Residential Exemption Received=$92,000, PALM BEACH SHORES,FL. 33404 a w 2010 REAL ESTATE Tax Information: Tax Rates:(per'$1,000 of valuation),.,- Community Preservation Act Tax $47.60 { '-Fire District Rates Town Residential Barnstable.FD-All Classes $2.43 $7.77 C.O.M.M.-All Classes. $1'..26 Town Commercial C.O.M.M.FD Tax(Residential) $373.21 Cotuit FD-All Classes $1.56 $6.87 y Hyannis-Residential $1.82 Town Tax(Residential) $1,586.63. Hyannis-Commer6iafl U.88 W Barnstable-All Classes $2.28 Community Preservation,Act 3%of Town Tax Total:$2,007.44 Construction Details Building - Property Sketch &ASBUILT Cards. Property Sketch Legend Building value $132,900 Interior Floors,A Hardwood Style Ranch Interior Walls Drywall Model Residential Heat Fuel Gas Grade Average Heat Type Hot Air ' Stories 1 Story AC-Type- Central Exterior Walls Wood Shingle Bedrooms 3 Bedrooms Roof Structure Gable/Hip Bathrooms 2 Full Roof Cover Asph/F GIs/Cmp Living Area sglft 1,232 Replacement Cost,$149,278 Year Built '1982 Depreciation 11 Total Rooms,F 6 Rooms Land Gross Area sq/ft 3,028 CODE 1010 Lot Size(Acres) 0.39 http://www.town.bamstable.ma.us/assessing/2010/dis'playparcel l 0map.asp?mappar=188156 12/3/2010 Barnstable Assessing Search Results Page 2 of 2 Appraised Value $160,000 As Built Cards: Assessed Value $160,000 `�' > view Interactive Maps » Sales History: Owner: Sale Date Book/Page: Sale Price: SHIELS,THOMAS L ET AL Jul 22 2003 12:OOAM C169925° $1 SHIELS,LEO G&GERTRUDE Aug 20 1998 12:00AM C149789= 1135,000 REYNOLDS,JERRY Oct 15 1994 12:OOAM C135193 $129,500 BARKSDALE,LEO H&ELEANOR, Nov 15 1982 12:OOAM C90068 $70,000 BARKSDALE,LEO DTHCRTM792 C90068 {` $1' Extra Building Features Code Description Units/SQ ft Appraised Value Assessed Value FPL1 Fireplace 1 $3,300 $3,300 Property Sketch Legend BAS First Floor,Living Area FST Utility Area(Finished Interior) UAT Attic Area(Unfinished) BMT Basement Area(Unfinished) FTS .Third Story Living Area(Finished) UHS Half Story(Unfinished) CAN Canopy FUS; ,Second Story Living Area(Finished) UST Utility Area(Unfinished) FAT Attic Area(Finished) GAR Garage UTQ . Three Quarters Story(Unfinished) FCP Carport GRN Greenhouse UUA Unfinished Utility Attic FEP Enclosed Porch PTO :Patio UUS..- Full Upper 2nd Story(Unfinished) FHS Half Story(Finished) SFB Semi Finished Living Area WDK Wood Deck FOP Open or Screened in Porch TQS Three Quarters Story(Finished) t . http://www.town.bamstable.ma.us/assessing/2010/displayparcel l 0map.asp?mappar=l 88156 12/3/2010 YOU WISH TO OPEN A BUSINESS? For Your Information: Business certificates (cost$ O_OQfor 4 years). A business certificate ONLY REGISTERS YOUR NAME in town (which you must do by M.G.L.-it does not give you permission to operate.) Business Certificates are available at the Town Clerk's Office, 1"FL. 367 Main Street, Hyannis, MA 02601 (Town Hall) DATE: l Fill in please: s M APPLICANT'S YOUR NAME/S: BUSINESS YOUR HOME ADDRESS: ? . \la\\�Jh'�•-� �c� TELEPHONE # Home Telephone.NumberG' NAME OF CORPORATION: NAME OF NEW BUSINESS ,—\\,.n c <o. TYPE OF-BUSINESS LrNnl:A<r C&P� IS THIS A HOME OCCUPATION? eYES 1 NO ` ADDRESS OF BUSINESS ::���� k,rl-)-av MAP/PAl4CEL NUMBER " �S Co (Assessing) When starting a new business there are several things you must do in order to be in compliance with the rules and regulations of the Town of Barnstable. This form is intended to assist you in obtaining the information you may need. You MUST GO TO 200 Main St. - (corner of Yarmouth Rd. &Main Street) to make sure you have the appropriate permits and licenses required to legally operate your business in this town.' 1. BUILDING COMMISSIONER'S OFFICE A �'ILJ. t?^,`r Cc.�'��•.r,•Cr -IV1<.�C.�'lr��iI1Ck-�E�4�Y,�f'�\��� �:a��v�,r�, This individual has been informed of any permit requirements that pertain to this type of business. .-V VAQ-3. Authorized Signature* �._ COMMENTS: . 2. BOARD OF HEALTH This individual has bee° ° r ed of the permit requirements that pertain to this type of business. MUST COMPLY WITH ALL . L ' ' "`r�1 HAZARDOUS MATERIALS REGULATIONS Authorized Signature*-* COMMENTS: 3: CONSUMER AFFAIRS (LICENSING AUTHORITY) This individual has been informed of the licensing requirements that pertain to this type of business. Authorized Signature** COMMENTS: