16 Complaint Records & Inspections Inspection Form
Northampton Board of Health,212 Main St., Northampton,MA 01060,413.587.1214
SSC 105 CMR 410.000: Chapter II, Minimum Standards of Fitness for Human Habitation
Date: 4.//y/ton Time: er: n #Occupants: #Children<6 Years —C
Address: I(jou s Sc. i t / CitylTown: rthampt� Ct-et
It�
Occupant Name: i-A tj/r1J TALLICNLC Phone# elle- 3 '7175
gwner Name: Phone# /Own" Hh�
Owner Address: City/Town: Zip Code:
#Dwelling/Rooming Units in Dwelling: #Stories: Z Floor Level of
Unit: - En- r -t kr
#Sleeping Rooms: #Habitable Rooms:
Inspector: Title:
If violations are observed and checked,describe them fully on Page 3.
Area or
Element
Type of Violation
Use blank boxes for ones not listed
Possible
Code
Section(s)
lit
Violation
Observed
Responsible Party
Owner
Occupa
nt
Exterior,
Yard &
Porch
Locks
480
Posting, ID, Exit signs/emergency lights
481,483,484
Handrails, steps, doors windows, roof
500,501.503
Rubbish—storage and collection
600,601
Maintenance of Area
602
Common
Areas&
Entry
Light,windows
253,254,501
Egress
450,451,452
Handrails
503
Door
501
Interior Halls
&Stairs
Floors,walls ceilings
500
Hallways, railings, stairs
503
Light, windows
253,254,501
Bedroom 1
Location(circle): Front Rear Middle Left Middle Right Floor Level
of Unit
Ventilation
280
Ceiling height
401.402
Windows, screen
501.551
Wall
500
Bedroom 2
Location(circle): Front Rear Middle Left Middle Right Floor Level
of Unit
Ventilation
280
Ceiling height
401,402
Windows, screen
501,551
Bathroom
sink, shower,tub, door
150
_Toilet,
Smooth, impervious surfaces
150
Area or
Element
Type of Violation
Use blank boxes for ones not listed
Possible
Code
Section(s)
✓ff
Violation
Observed
Responsible Party
Owner
Occupe
nt
Lights, outlets, ventilations
251,280
Floors/walls
504
Kitchen
Kitchen,
coot
Sink, stove,oven;good repair, impervious and
smooth, space refrig
100
Lights, outlets, ventilation, windows, screens
251,280,501,
551
Floor height
401 402
Alt"a"r
504 rice-Aar
Floor pp, ot.n yt,7r,.a,1-ko Na£s
Floors/VValls
500
Living room
and Dining
Room
Lights, outlets,ventilation
250.280
Ceiling height
401,402
Windows/screens
501,551
Ceiling condition
Sink
Basement
Maintenance
500
Watertight
500
Lighting
253
0"- — (Sate W%215 15 �!
Water
Source(circle): Public Private
Must be potable
180
Quantity, pressure
180
Responsible for paying MGL ch 186 s 22, metering
354
Hot Water
Fuel Type(circle): Natural Gas Oil Electric Other Temp.: 56 °f Location
taken: Kitchen
Quantity, pressure 110 F min, 130 max
180
Venting
202
Heating
Type(circle): Forced Hot Water Forced Hot Air Steam Electric
No portable units
200
"Habitable room and every room with toilet, shower,
tub"
201
• 68F7 am toll pm,64F 11:03 pm to 6:59 am,
except 6/15-9/15
• 78 F max in heating season/measure 5 feet wall,5
feet floor
Venting, metering
202,354,355
Electrical
Type(circle): 110 220 Amp:
Amperage,temporary wiring, metering
250,255.256,
354
Drainage,
Plumbing
Type(circle): Public Private
Sanitary drainage required and maintained
300,351
Smoke&CO
Detectors
Required &operational
482
Emergency lights
Area or
Element
Type of Violation
Use blank boxes for ones not listed
Possible
Code
Section(s)
:fit
Violation
Observed
Responsible Party
Owner
Occupa
nt
Pests
Free of pests(rodents skunks, cockroaches insects)
550
if
Structural maintenance and elimination of harborage
550
1sbestos or
Paint
353,502
.ead
:urtailment
620
tccees
810
Mier
Referral:
0 Electric 0 Fire 0 Plumbing 0 Building 0 Other
This inspection report is signed and certified under the pains and penalties of perjury.
Inspector Signature: eri�E«`-
Occupant or Occupant's Representative Signature; l ,. p13c_ (n 41
Reinspection Date: 712-0 Time:
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BOARD OF REAL
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COMPLAIN ,RECORD"
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Location: I(o ` \
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Owner:
Address:
Tel:
Taken Date of Inspection:
'Time:
INSPECTOR'S REPORT:
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Total#of Inspections: t Orders Issued?: AiD
Date of Final Inspection: _P-• Notice of Compliance?: x�
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Inspector Signature
BOARD OF HEALTH
CITY HALL
COMPLAINT RECORD
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Date:)1 'Time: I
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Map:
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Name of Complainant: UlJh0-(1R._.1 \\ Ie4k U-I
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Tel:(. 54
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NATURE OF COMPLAINT: C
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Owner: 4{„j--.
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Address: I
Tel:
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Dfte of Inspection: I Time:
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INSPECTOR'S REPORT:
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Action Taken:
Inspector Signature
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