10 Deleading Notification 2002 Department of Heblic Wealth/Department Of Labor 6 Industries
NOTIFICATION OF DELEADING WORK FILE NUMBER
All sections of this form eat be completed in order to comply with
the notification requirements of I4.G.L.C. 111 4 197,
454 ON 22.00 and 105 Ola 460.000 as most recently attended
Contractor performing project' pi\h N r License & Date "O C 3
Lead Paint Inspector ygt*t. CNttttQ t
License t Malay
PROPERTY MINER (If owner or unlicensed owner's agent will be performing low—
risk deleading work, 2 p�
complete the following ):
Property Owner Agent(e) I�
�
JUN I
Address Lfl N p 7 xyp 'IlLii
INORTHAMPfON SDARD OF HEALTH I
I certify that I have complied with the
la ion ,training rcIRi 460.175 of the na Commonwealth to of Massachusetts teed
Poisoning
inme Prevention. 1 f�rt further eomfyl Regulations,.y 105 will l6be per for
rm owner/agent the tw-risk w-riskeat and
containment. 1 fihatea plytify that I or N agent sill be performing the s•follwittq low-risk activities (I
have circled all that apply):
applying liquid encepsulnt capping baseboards removing doors, cabinet doors, shutters
applying exterior vinyl siding covering surfaces
I certify that all the information contained in this notification is.true and correct to the best of my
bmeladge and belief.
Telephone Number
Date: Signed:
ADDRESS OF PROJECT: 1� p,�
Street Address Vb Fy\1S0.\C`J�O. 3Nvee c Apt. Number
City 1�1(11T'tt�CCS Zip t:\ AL)C)
9 11`..�dli]i �
PropertyOwner CR�\*:x @ITS e. Addres s " �'c
`%
Telephone Number \b 'rjya — 'fjgO�p N t ` �`�a
Deleading Method: Net/Dry Scraping Heat Gun _liquid Encapaulant
Demolition CausticseplacementT
Covering Other
If 'Tither" selected, please explain
Check one:
dwelling is multi—family Y
other
Page 2 of 2
Start pate \n -\S-(Zia
Completion date 2L-a.$Pk-Qa
When will work be done: �aam_.J pm52C Specify times coffin, site) Weekends?��
Project Supervisor Name S 'R. tvv\C. . J�yQ , License#V.\'*k Exp. Date% 4■-CZN
Workman's Compensation Policy dumber\WFC1S13\5L\-\p Carrier__
In Case of Emergency Contact: �]hY\lX��i�PRO )Contractor's Representative)
I\\ )-05
In accordance with Massachusetts General Laws C. 111 4197, 454 CNR 22.00 and 105 OM 460.000, notice of the
date and method(s) of remove or covering of paint, plaster or other accessible materials containing
dangerous levels of Lead is to be provided and must be received by the following persons, at feast ten
business days prior to the beginning of deteeding. NOTIFICATIONS MAY BE FAZED.
1. Department of Labor & Industries, Division of Asbestos and Lead Enforcement
100 Cambridge Street, Rocca 1106, Boston, MA 02202 FAX: (617)727-7568
2. Director, Childhood Lead Poisoning Prevention Program
Department of public Health, 305 South Street, Jamaica Plain, MA 02130 FM: (617) 9634914 c70L1—aLx >'O
3. Occupants of dwelling unit (617) 832.8735 a8y. t�y�
t
4. All other occupants of the residential premises, if any
5. Local Board of Health/Code Enforcement Agency
6. Massachusetts Historical Commission (if premises are listed on the State Register of Historic
220 Morrissey Blvd. Places, this notification lust be made upon receipt of an
Boston, MA 02202 Order To Correct Violations or at least 30 days prior to
FAX: (617)727-5128 initiating preventive deleading)
DELEADING CONTRACTOR:
The undersigned hereby states, under the pains and penalties of perjury, that
he/she has read and understood the Commonwealth of Massachusetts Deleading
regulations, 454 CMR 22.00, add-Lead Poisoning Prevention and Control
Regulations, 105 CNR 460.000, and that the information contained in this
notification is true and correct to the best of his/her knowledge and belief.
Date \p-'jV-boa ry y� Signed
Company Name: \`72V\'t‘ ` • Hekcc.
Address:
Telephone Number:
"%\- -eaal.-3\\n6
•■�•A�tlt.
NOTIFICATIONS SHALL BE COMPLETED IN THEIR ENTIRETY, DATED AND SIGNED —
INCOIPLETE NOTIFICATIONS WILL NOT BE ACCEPTED AND WILL BE RETURNED BY D.L.I.