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HomeMy WebLinkAbout1643 HYANNIS ROAD - Health l 643 ,Hyaimis Road r _ _ Barnstable:; - A= 299-001 -001 r, q v s e u No. W; Fee BOARD OF HEALTH TOWN OF BARNSTABLE : 01ppYtcation -for Vern Construction J)ermtt Application is hereby made for a permit to Construct K, Alter( ), or Repair( ) an individual well at: II.Q q-�� H-vQ n Rd, 6arn e, 2aa/0 t)I I a 1> I ocation-Address Aspssorl Map and Parcel L n v- (Stove- Hes/jtiQei- iC9 n , UAL F Owner Address V C)Z(� ) Installer-Driller Address Type of Building Dwelling Other-.Type of Building No. of Persons Type of Well 411 `' LVV—d. Lfb P V1✓ Capacity 2-15 Purpose of Well i r r i a-i'Ip n Agreement: The undersigned agrees to install the afore described individual well in accordance with the provisions of the Town of Barnstable Board of Health Private Well Protection Regulation-The undersigned further agrees not to place the well in operation until a Certificate of Complian has been issued by the Board of Health. Signed 1151zoz.) Date Application Approved By a°! Date Application Disapproved for the following reasons: Date Permit No. W ! Issued Date BOARD OF HEALTH TOWN OF BARNSTABLE (Certificate of Compliance THIS IS TO CERTIFY,that the individual well, ,Constructed P(.� Altered( ), or Repaired( ) by 09,S? t ` d, \N o 1.1 n Y I I j l m inc , Installer at ) (()L4'�) ft `&_SLZ &I--e- has been installed in accordance with the provisions of the Town of Barnstable Board of Health Private Well Protection Regulation as described in the application for Well Construction Permit No. W�-O 015 Dated '3 --a7-X/ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORILY. Date Inspector No. V" °�I Fee BOARD OF HEALTH TOWN OF BARNSTABLE 2ppricatiou jfor Yell Con5truction Permit Application is hereby made for a permit to Construct(<), Alter( ), or Repair( ) an individual well at: 1648 Hvann ade, 2cic1/OD1 0D i Location-Address Assessors Map and Parcel Owner ✓ , l J _ Address � j Sr»ohd weII f�r�LLrl, lW-, P1) 6ox 27X-3 . 069 Wn� . NA 0Z �� Installer-Driller L/ `Address I Type of Building Dwelling Other-Type of Building No. of Persons . Type of Well i Y l�' � '.. Capacity - Purpose of Well f Y 1 CA Ck.1 i !7` v Agreement: The undersigned agrees to install the afore described individual well in accordance with the provisions of the Town of Barnstable Board of Health Private Well Protection Regulation-The undersigned further agrees not to place the well in operation until a Certificate of Compliance has been issued by the Board of Health. j Signed �A. .. { � � C� Date Application Approved By UDate Application Disapproved for the following reasons: r Date Permit No. �0 015 Issued J °z Date BOARD OF HEALTH TOWN OF BARNSTABLE Certificate of Compliance THIS IS TO CERTIFY,that the individual well Constructed�(4), Altered( ), or Repaired( ) by C&SM(--nA \)Ve1 YiIIIOC4 a 1hC �IInstaller at CC H-L4 cc.}fir`)Lq Rd,, �a r n., 1 L! has been installed in accordance with the provisions of the Town of Barnstable Board of Health Private Well Protection Regulation as described in the application for Well Construction Permit No. W;0 a 1-015 Dated X/ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORILY. Date Inspector ----------------- .__-_ ___- _-.,_____-- . __ _ — __ -_ ---_. _ ---------------------- BOARD OF HEALTH TOWN OF BARNSTABLE Vern Construction Permit No. W Oa 6 5 Fee t Permission is hereby granted to � ��n©� �= G 1 (l 1 r f, , le Installer /{ to Construct�( ), Alter( ), or Repair( an individual well at: Street as shown on the application for a Well Construction Permit No. _ Date LDate 01 ! f Approved By r • 1� l«[Irlt i�r ` • r aO's l � ti'fs Massachusetts Department of Environmental Protection L Bureau of Resource Protection Well Completion Reports Well Driller Please specify work performed: Address at well location: New Well Street Number: Street Name: 1643 HYANNIS RD Please specify well type: Building Lot#: Assessor's Map#: Irrigation --� 3 Assessor's Lot#: ZIP Code: Number Of Wells: 24 02630 Cityfrown: Well Location BARNSTABLE In public right-of-way: GPS (7,Yes C',No North: West: 41.69640 70.30297 Subdivision/Property/Description: Mailing Address: ''click here if same as well location address Property Owner: Street Number: Street Name: STEVE AND LYNN HESLINGA 1643 HYANNIS RD City/Town: State: Engineering Finn: r BARNSTABLE MASSACHUSETTS ZIP Code: 02630 Board of health permit obtained: C7 Yes C`Not Required Permit Number: Date Issued: W2021015 03/29/2021 -� r Massachusetts Department of Environmental Protection Bureau of Resource Protection—Well Driller Program Well Completion Reports(General) Well Driller - General Well Form DRILLING METHOD Overburden Bedrock ,Auger Choose Bedrock— WELL LOG OVERBURDEN LITHOLOGY _ Fro (ft) TOM Code Color Comment Drop in drill Extra fast or slow Loss or addition stem drill rate of fluid 0 20 Fine To Coarse S .� Brown ('r Fast(�Slow YES NO Loss Addition 20 40 Silty Sand Brown ; Fast i^Slow (' [ LYE ��� ��� o. 40 —1 50 Silty Sand + YES N �Fast r Slow L0 � ---- � � .•.-. �� Brown� � S NO Loss Addition 50 55 Fine Sand ! Brown (t°Fast C Slow YES NO .� Loss Addition 55 60 Fine To Coarse S f'� Brown + (`Fast( Slow LL.ss [ YES NO - ---- --.---- . Addition 60 65 (Medium Sand Brown r,,Fast r Slow j =YESNO Loss Addition WELL LOG BEDROCK LITHOLOGY Drop in Extra fast or Loss or Visible Rust Extra [From(ft) To(ft) Code Comment addition of Large drill stem slow drill rate fluid Staining Chip s t J Choose Code r Yes Yes [YES N.0 Fast Slow Loss Addition _..� ADDITIONAL WELL INFORMATION Developed C Yes (.No Disinfected C Yes C No Total Well Depth 65 Depth to Bedrock Surface Seal Type None racture Enhancement CASING 177,Is Casing above ground? From To Type Thickness (Diameter Driveshoe 61 Polyvinyl Chloride Schedule 40 — LY r Yes SCREEN �i No Screen From To Type Slot Size Diameter 61 85 Stainless Steel Well Point WATER-BEAMNG ZONES iff DRY MLL From — To Yield(gpm) Massachusetts Department of Environmental Protection Bureau of Resource Protection—Well Driller Program Well Completion Reports(General) I� 41 165 112 PERMANENT PUMP(IF AVAILABLE Wire Constant Speed 1 Pump Description Horsepower Submersible 1/2 Pump Intake Depth(ft) 60 Nominal Pump Capacity(gpm) 25 ANNULAR SEAL/FILTER PACK [From To Material 1 Weight Material 2 Weight Water Batches Method Of (gal) (count) Placement 0 1 Choose Material � r--� Choose Material --� —Choose One ..........._. ._.._.... ............. ... ...... ... .. .....__.._..... .........._..._.............-.. .............--- . ------ C WELL TEST DATA Date Method Yield(gpm) Time Pumped Pumping Level(ft Time To Recover Recovery(ft (HH:MM) BGS) (HH:MM) BGS) 05/19/2021 Constant Rate Pump _ 12 01,30 47 -- 00:01� 41 — WATER LEVEL Date Static Depth BGS(ft) Flowing Rate(gpm) Measured 05/19/2021 41 12 COMMENTS WELL DRILLERS STATEMENT This well was drilled or altered under my direct supervision,according to the applicable rules and regulations,and this report is complete and accurate to the best of my knowledge. WILLIAM Supervising Driller DESMOND, DrillerURQUHART Registration# 877 Monitoring[M] Signature PATRICK, DESMOND WELL ' Date Job Complete Firm DRILLING INC. Rig Permit# 0551 06/15/2021 NOTE:Well Completion Reports must be filed by the registered well driller within 30 days of well completion. ENVIR 0 TECH LAB ORA TORIES,INC. IYIA CERT.NO.:M-MA 063 8 Jan Sebastian Drive Unit 12 Sandwich,MA 02563 (508)888-6460 1-800-339-6460 FAX(508)888-6446 Client Name: Desmond Well Drilling Location Address: PO Box 2783 1643 Hyannis Rd Orleans, MA Barnstable,MA 02653 Lab Number: DW-212074 Collected By: DWD Date Received: 05/20/21 Sample Type: Well Well Specs: Irrigation 65/41 LocaSnn",Source µ Date Collected 77nre GolfecPed `` Convns vc, a ak a^ ?' aa ar„�^ -'" pir 6 RC inkxia m:.9i r v ., 4 a � a Analysis Requested — Units ;Recommended Limlfsj Analysis Result I Method lbate Analyzed Analyzed By Total Coliform CFU/100mL 0_ 0,B-G 0 SM9222B 05/20/2021 NB @ 1430 pH pH units 6 5 8 5,.., 6.23 _SM 4500-H B 05/20/2021 SD Specific Conductancep' umhos/cm_ 500 264 _EPA 120.1 1, Q5/20/2021 SD Nitrite-N mg/L 1.00 <0.006 EPA 300.0 05/20/2021._ SD Nitrate-N - nig/L 10 0 9.30 "EPA 300.0- "-05/20/2021 SD Sodium mg/L 20.0 44 EPA 200.7 "' 05/21/2021 "KB Total Iron mglL 0 3 015 EPA 200.7 -05/21/2021 KB w. Manganese mg/L 0.05 0183 EPA 2007 05/21/2021 KB Comments: Nitrate level should be monitored periodically. pH is below recommended limit and may have corrosive characteristics. Sodium level is not a health hazard. Over a lifetime,the EPA recommends that people drink water with manganese levels less than 0.3 mg/L and over the short term,EPA recommends that people limit their consumption of water with levels over 1.0 mg/L All samples were analyzed within the established guidelines of US EPA approved methods with all requirements met, unless otherwise noted at the end of a given sample's analytical results. We certify that the following results are true and accurate to the best of our knowledge. Water meets EPA standards and is suitable for drinking for parameters tested. w Date 5/25/2021 Ronald J.Saari Laboratory Director BRL=Below Reportable Limits *See Attached Page 1 of 1 °Certification is not available for this analyte for potable water samples.. ` .. V'r Date 17 To Whom It May Concern: I, *//177 l voluntarily grant permission to the Town (occupants nam of Barnstable Board of Health(Agent or Health Inspector)to inspect my dwelling unit located at6f (House Apt\Unit#if applicable),street,village) with the Town of Barnstable Code(Chapters 59 and 170)and the State Sanitary Code (105 CMR 410.000)on_ �/ I hereby authorize and name �e ofAspection)ofAspection) to be my tenant representative for the ( repre tive) purpose of this inspection. an adult person (Occupant representative) designated and duly authorized to act on my behalf and will be accompanying the Town of Barnstable Board of Health for the inspection;granting access to any and all locations (including bedrooms,bathrooms, closets,etc.,) allowing the use of photographs and answering questions. This authorization is only valid for the inspection date specified above, and must be renewed for any future inspection(s.) KAU Occupants Si ture \ Date \ mar/ Occupants Representative Si tore \ D e TOWN OF BARNSTABLE BOARD OF HEALTH ARTICLE II: MINIMUM STANDARDS FOR HUMAN HABITATION Date '� —�I Time: In Out Owner a Tenant I P q Address 6 1 Address 6 3 Complia a Remarks or Regulation# Yes O Recommendations 2. Kitchen Facilities 3. Bathroom Facilities 4. Water Supply 5. Hot Water Facilities 6. Heating Facilities pmvel 7. Lighting and Electrical Facilities 8. Ventilation 9. Installation and Maintenance of Facilities 10. Curtailment of Service 11. Space and Use 12. Exits 13. Installation and Maintenance of Structural Elements 14. Insects and Rodents 15. Garbage and Rubbish Storage and Disposal 16. Sewage Disposal 17. Temporary Housing 18. Driveway Width 19. Number of Tenants Observed PART II 37. Placarding of Condemned Dwelling; Removal of Occupants; Demolition Number of Bedrooms Number of Vehicles Allowed (max) Number of Persons Allowed (max) Person(s) Interviewed Inspector. If Public Building such as Store or Hotel/Motel specify here , - Date To Whom It May Concern: I, << /z:;r_ ,voluntarily grant permission to the Town (Occupants name) . of Barnstable Board of Health(Agent or Health Inspector)to inspect my dwelling unit located at ce (House#, [Kpt\lJnit#if applicable),street,vil age) with the Town of Barnstable Code(Chapters 59 and 170)and the I State Sanitary Code (105 CMR 410.000)on I hereby authorize and name op ate o inspection) /i to be my tenant representative for the (Ocaipant representative) purpose of this inspection. -I-X,-Q an adult person (Owupant representative) designated and duly authorized to act on my behalf and will be accompanying the Town of Barnstable Board of Health for the inspection, granting access to any and all locations (including bedrooms,bathrooms, closets, etc.,)allowing the use of photographs and answering questions. This authorization is only valid for the inspection date specified above, and must be renewed for any future inspection(s.) Occupants Signature 1 Date Occupants Representati ignature \ Date ti TOWN OF BARNSTABLE BOARD OF HEALTH ARTICLE II: MINIMUM STANDARDS FOR HUMAN HABITATION Date 1 — Time: in Out Owner 1 f Tenant Address �o _l. Address Compl'ince Remarks or Regulation# Yes NO Recommendations 2. Kitchen Facilities 3. Bathroom Facilities 4. Water Supply 5. Hot Water Facilities 6. Heating Facilities 7. Lighting and Electrical Facilities 8.Ventilation 9. Installation and Maintenance of Facilities 10. Curtailment of Service 11. Space and Use 12. Exits 13. Installation and Maintenance of Structural Elements 14. Insects and Rodents 15. Garbage and Rubbish Storage and Disposal 16. Sewage Disposal r 17.Temporary Housing 18. Driveway Width ' IL l 19. Number of Tenants Observed PART II 37. Placarding of Condemned Dwelling; Removal of Occupants; Demolition Number of Bedrooms' Number of Vehicles Allowed (max) Number of Persons Allowed (max) Person(s) Interviewed Inspector If Public Building such as Store or Hotel/Motel specify here APR.14.2010 10:05AM BARNSTABLE BOARD OF HEALTH NO.866 P.1/1 Date To Whom It May Concern: I, ,.�`�'/� �� ,voluntarily grant permission to the Town (Occupants name) of Barnstable Board of Health(Agent or Health Inspector)to inspect my dwelling unit located at /Lq 2fae - in accordance (House#; Ap nit#if applicablo),street village) with the Town of Barnstable Code(Chapters 59 and 170)and the State Sanitary Code (105 CMR 410.000)on 9 c�2 P/0 I hereby authorize and name-. (Dato o pection) to be my tenant representative for the , (Occupant representative) purpose of this inspection. is an adult person (Occupant representative) designated and duly authorized to act on my behalf and will be accompanying the Town of Barnstable Board of Health for the inspection,granting access to any and all locations (including bedrooms,bathrooms,closets,etc,,)allowing the use of photographs and answering questions.This authorization is only valid for the inspection date specified above,and must be renewed for any future inspection(s.) Occupants Signature 1 Date O cupants Representative S' ature \ D to Q:\Rental OrdinaneeMnapcction permission 2.doc TOWN OF BARNSTABLE BOARD OF HEALTH ARTICLE 11: MINIMUM STANDARDS FOR HUMAN HABITATION — f Date l CD Time: In Out Owner Tenant Alw�� Address VL j 4nf;R Address Com Iia9ce Remarks or Regulation# Yes NO Recommendations 2. Kitchen Facilities 3. Bathroom Facilities 4. Water Supply fit ,,, . 5. Hot Water Facilities 6. Heating Facilities 7. Lighting and Electrical Facilities _ 8. Ventilation 9. Installation and Maintenance of Facilities 10. Curtailment of Service 11. Space and Use 12. Exits 13. Installation and Maintenance of Structural Elements 14. Insects and Rodents 15. Garbage and Rubbish Storage and Disposal 16. Sewage Disposal 17.Temporary Housing 18. Driveway Width on 19. Number of Tenants Observed PART II 37. Placarding of Condemned Dwelling; Removal of Occupants; Demolition Number of Bedrooms Number of Vehicles Allowed x) Number of Persons Allowed (max) Person(s) Interviewed Inspector If Public Building such as Store or Hotel/Motel specify here f _ FORM30 &W HOBBSBWARREN'M THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH CITY OWN F a � DEPARTMENT ADDRESS , 4�M sey`0 � � f P4--Occupant TELEPHONE 6Address t Floor Apartment N No. of Occupan No. of Habitable Rooms No.Sleeping Rooms No.dwelling or rooming units N 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: 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 f) Bedroom 2 Bedroom 3 1 Bedroom 4 Hot Water Facil. Sup.Ten.,Gas, Oil, Elect.: , FI es,V n Safeties: Kitchen Facilities ink 0 S ove Bathing,Toilet Facil. Vent., Plumb.,Sanit'n.: ` Wash Basin,Shower or Tub: Infestation Rats, Mice, Roaches or Other.- Egress Dual and Obst'n: General Building Posted Locks on Doors: ONE OR MORE OF THE VIOLATIONS CHECKED ABOVE IS A CONDITION WHICH MAY MATERIALLY IMPAIR THE HEALTH OR SAFETY AND WELL-BEING OF THE OCCUPANT AS DETERMINED BY 105CMR 410.750 OF THE CODE OR THE AUTHORIZED INSPECTOR. (See Over) "THIS INSPECTION REPORT IS SIGNED AND CERTIFIED UNDER THO PAINS AND PENALTIES OF PERJURY.' e�_. af - INSPECT0R2-10 -0j� TITLE �1 DATE TIME V -� 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. � W HOBBSBWARRENTM THE COMMONWEALTH OF MASSACHUSETTS FORM 30 CA BOARD OF HE LTH I CI7416tw /TO a, S+ + DEPARTM NT ,^ ADDRESS I M sey`0 TEL EpHONE Address ' Oy 3 I / _Occupant - X�/ hxt-�� Floor Apartment o. /"T No. of Occupants No. of Habitable Rooms No.Sleeping Rooms— No.dwelling or rooming units .Stories Name and address of owner 16 C.( 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 YL 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 ice 2 Bedroom 1 7 Bedroom 2 Bedroom 3 Bedroom 4 Hot Water Facil. Sup.Ten.,Gas, Oil, Elect.: Stacks, Flues,Vents,Safeties: Kitchen Facilities Sink Stove Bathing,Toilet Facil. Vent., Plumb.,Sanit'n.: Wash Basin,Shower or Tub: Infestation Rats, Mice, Roaches or Other: Egress Dual and Obst'n: General Building Posted Locks on Doors: ONE OR MORE OF THE VIOLATIONS CHECKED ABOVE IS A CONDITION WHICH MAY MATERIALLY IMPAIR THE HEALTH OR SAFETY AND WELL-BEING OF THE OCCUPANT AS DETERMINED BY 105CMR 410.750 OF THE CODE OR THE AUTHORIZED INSPECTOR. (See Over) "THIS INSPECTION REPORT IS SIGNED AND CERTIFIED UNDER THE PAINS AND PENALTIES OF PERJURY." INSPECTOR TITLE I%���i � (� A.M. DATE 15 �� _ �� TIME f P.M. A.M. THE NEXT SCHEDULED REINSPECTION J 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. :--- i -. i j i ''� i � f � i k L_ - -: - _ ., FORM30 C&w HOBBSB WARREN TM THE COMMONWEALTH OF MASSACHUSETTS ti ELC R Q OF x LTH CI /TOW I a DE TMENT ` ADDR 'G7M SVBy`0W .. MLEPfN Address �Occu a �xtha (JJ�/�� Floor Apar ent,No. No. of Occup is �No.of Habitable Rooms— L No.Sleeping Rooms No.dwelling or rooming units No.Stori s Name a . ad-',-ssol owner I S Remarks Reg. Vio. YARD Bld s.: ences: Garbage and Rubbish Containers: , 1. Drainage wo y1ulcul 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 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 1205-C al__ 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 INSP CTION T IS SIGNED AND CERTIFIED UNDER THE PAINS AND PENAL TIE F E Y. INSPECTOR TITLE A.M. DATE v 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 fora 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. 9 9 ( 9 ) (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 r ! P i I 7 { I f f r s j 4. a t i E f� f t FORM 30 C&W HOBBSB WARREN TM THE COMMONWEALTH OF MASSACHUSETTS B QA- RD � ALTH rlj CITY/TOWN o * AAW V• EA TMENT 1 - A RESS GSM SVey`0w PLEPHONP 1 —lei • p Address Occu an Floor Apartn e No. Jq No.of Occupants No.of Habitable Rooms No.Sleeping Rooms-_ No. dwelling or rooming units No.. ories Name and [a/ores o owner Remarks Reg. Vio. YARD t 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.: 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 PORT IS SIGNED AND CERTIFIED UNDER THE PAINS AND PENALTI FVIA " INSPECTOR TITLE A.M. DATE TIME 1 / 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,rpressure'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. t (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. » ��Z)