70 Notification of Deleading Work 2005 a ..
Department of Public Health/Department of Labor&'Workforce Development
NOTIFICATION OF DELEADA'G WORK
Ali section,of this form must he completed in order to comply with
the notification requirements of M.GL C.111§197,
454 CMR 2200 tad 105 CMR 460.000,as most recently amended
cmiractorperamminpmioakbidDeIDD.{N.TilliammgDC001614,9.Tho
Lead Paint Instmctor One of tu.peatdo.
L'uum0 Eng.Date
8/30/05
HAMPTON BOARD OP HEALTH
ADDRESS OF PROJECT'SUN n7 Si eke_ r.— Cgcc
7. 0I Pare.di, c APL Number
City M pIY'V`(\
Property Ow.er Soh /Op Carl t5C Address Wes
IL , -1- S-F +,- t .i,MR OIx'
Street Address
Zip 0 V o(nc
telephone Number 413_ S$S _ 221 ebadiag Method: ....,.,,,o.. Sr/1 Heat Gun
Caustics
Other
If"Other"selected,please explain
Liq.id Enupsalau
Reidagemeot
Check one: Dwelling is moiE.fmdt
Start Date g11RI05
Soigle-tmly.
Completion Dais 8131
When will work be done: AM77 00EM 5:0°Sputbt times on aim s no
Weekends?
ProjectS.ptman/Name Jerry Gray Liming.DS00377 C4 DaleQl i'05 (,i,SeteML4ed}
Worker's Compensation Policy Number AWC7013278012003000 Carrier MM
la case of emergency cement Fran Tilli, . Abide,Incyud 4 13 525-0644
(Contractor's Representative)
DELEADING CONTRACTOR
The undersigned hereby stall,under the pals and penalties of perjury,tot he/she has read aid understood the Contaminant'of
Massachusetts Deleading Reguia4ue,454 CMR WM,and the Lead Poisoning Prematb.and Compel Reguladena 105 ChM 460.004.sad
that the information eaatai.ed I.tkle.o0tioatie.Is true and en to the but ofhiather knowledge and belief
Data
7 25/05
companvName Abide, Inc.
Signed
Frank Tilli, Abide, Inc.
Address P.O. Box 886 (483 Shaker Rd. ) , East Longmeadow, MA 01028
Telephone Number (413) 525-0644
OVER-*
Page 2 or 2
accordance with Maauch. sus Cement Lanes c.III§197,454 CMR 22.00 cad 105 MR 460.9110,notice of die date tad memad(s)of
removal or covering of paint,plaster or other seeuviMe materials totalling dagerom Inds of keg is to be provided and most be received
by thef i owlag agenda,at least IM f(10)days prior to the beginning ofdeleading.
NOTIFICATIONS MAY BE FAXED.
Departmeat of Labor and Workforce Development,Dirhioa of Occupational Safety
399 Washington Street,3's Floor,Roston,MA 02108 FAX(417)7/7-753
i Dinnan.tlildlwad Lead Poisoning?mean**Program IDi
Department olPahaeHnith,54Roland Street,Suite 100,Boton,MA02129 £�
3. Occupanh dawdling oak
4. AB other mamma of the residential premises,if any
Local Board of HaD6ffde Eufurwnr Agency 6yorThpl,„„4: ) FA (k() 5$`I
Tq"774t-670D
MmgvhuseW Hbterital Communion
220 Mortbwy Blvd.
Boat..,MA 02202
FAX(617)7275128
(if premises are lirted oar the State Register atHatork
Naas,the notification moat be made aptot receipt of an
Order to Correct Violation or at least 30 drys prior to
teitittlag preventive dekadiag)
a
NOTIFICATIONS SHALL BE COMPLETED IN'HOUR ENTIRETY,DATED AND SIGNED-INCOMPLETE NOTIFICATIONS WILL NOT
BE ACCEFIED AND WILL EE RETURNED BY THE DEPARTMENT OF LABOR&WORKFORCE DEVEIAPAPNT.
PItOPE611.OWAO (I£mw unlicensed owner's agent will be perfmninglow•riddeleadingwaft,complete the% svitRT
Property Owner
Adam, P.O. Box 886 (483 3I> ker Rd. ) , E.Longmeadow, MA 01028
Tekpbeae Norther (413). 525-0644
I certify that I have complied with the training requirements tattle Ccmuncetwa1 h ofMaosedemens Lead Poisoning Prevention tad Cannot Regulations,105
CMR 460.175,forownefagent low-tilt abetment and containment I further ea*that I or my ogaa 4fl be perfmareg We following lava;&adivitia
(I have dieted all tartgply'):
Agent(.) Jo Densmore - AbidP, Tnc.
applviug IigWN nnpnre.t
applying exterior vinyl Min
I certify that
Date
tapping baseboards naaarlag doors,object doom,tboaen
coveting surface
the inlbrmefion contained in this notification is true mrectra the beg of my k�wi.dga and betieL
Signed
Jo Denem e - Abide, Inc.
Authorization 4 04488-AL
a b i d e
Abide, Inc., Environmental Contracting
LEAD NOTIFICATION FAX COVER SHEET
DATE: %/2S1n5
ATTENTION: FAX#:
or,CLPPP(Boston) 781-774-6700
hector,LEAD�PROGRAM(Boston) 617-727-7568
Town/City of / t,icii CtoAfjtV1 YR Sf'(ZZ-/
(Local Board of Health)
Massachusetts Historical Commission 617-727-5128
FROM: FRANK TILLI/ABIDE,INC.
REGARDING:
[� PROJECT NOTIFICATION
[ ] REVISED NOTIFICATION
[ ] OTHER:
NUMBER OF PAGES (including this one
COMMENTS:
If you experience problems in receiving this transmission,please call413-525-0644.
CONFOEN1IAVIY NOTICE: The documents accompanying this tclempy transmission may comat mafdeatialmd(instal
.. . inform:im Sinn Abide,lac.'Ms sdoamSas Seated forlhe tinofdie addressed individual of
ally. tfyou're not the hiIc dd=CWkd,be awn that any disclosure,copysg,dsmbidoo,or.
use of the coateats of this transmission is prohibited. If you SWtoedvedfhs tnmmisveriia mcr,
Oast notify vs by telephone(413-525-0644)hamedstrly.TTmnky=
P.O. Box 886 East Longmeadow, MA 01028
Phone 413-525-0644 • Fax 413-525-0678 • www.abideinccofn
Abide,Inc.'s standard TERMS AND CONDITIONS require payment for san c*s upon praammlon of Imolea Invokes unpaid after 30 DAYS are pest this and'Word to
a FINANCE CHARGE compiled at a monthly nate of 1 1/2%(ANNUAL PERCENTAGE RATE OF 18%)or the maximum paruntsye allowed by tlw law. Curd Is -
responsible IN legal and odgetlkn coat a necessary to collect past din anmunt.