38 Deleading Notification 2001 ..
Department of Public wealth/Department Of Labor 6 Industrie
NOTIFICATION OF DELEADING WORK
All sections of this form ant be cnpteted in order to empty v'th
the notification requirements of M.G.L.C. 111 § 197,
454 OIR 22.00 and 105 CRR 460.000 as most recently emended
Contractor performing project\j'frV0
/� ill .��1r;,,t�License #g\tiV�Exp.
Lead Paint Inspector 4\r,\--..e ` # Ns-11�
T'f`L�l�� License i
PROPERTY OWNER (If owner or unlicensed owner's agent will be performing low-
risk deleading work,
complete the following ):
Property Owner
Agents)
[NI m
I ,jr
a 23 2001
Address
Telephone Number
I certify that I have complied with the training requirements of the Commonwealth of Massachusetts Lead
Poisoning Prevention and Control Regulations, 105 DiR 460.175, for ewer/agent Lau-risk abatement and
containment. I further certify that I or my agent wilt be performing the +-following low-risk activities (I
have circled all that apply);
applying liquid encapsulant 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
knowledge and belief.
Date: Signed:
ADDRESS OF PROJECT:
Street Address
City
PropertyOwner
Telephone Number ` g,['Cc fl
Deleading Method: Wet/Dry Scraping
Demolition
Covering
If "Other" selected, please explain
Apt. Number
Zip GAG
Address' ,'
,-\\b -%ya-E No � v C t1P. G\Cbc
Heat Gun Li id Encapsulant
Caustics + e lacemen
Other
Check one: dwelling is multi-family
other
single-family
Page 2 of 2
Start Date -o\
Completion date V—"\-C 1
When will work be done: anj 3 pailAAS4Specify times on site) Weekends?�
Project Supervisor Name \'KVC<\Q- I 3/442hO Licenseft-\'AS Exp. Date \--5
Workman's Compensation Policy NumbeAC.`i)F•SFi°'i8�t.::1\q Carrier ZZ A s _
In Case of Emergency Contact: Yt'tR^.(Contractor's Representative)
"t\b-OJdZ--V\bSs
In accordance with Massachusetts General laws C. 111 4197, 454 CAR 22.00 and 105 DIR 460.000, notice of the
date and method(s) of removal or covering of paint, piaster or other accessible materials containing
dangerous levels of lead is to be provided and mat be received by the following persons, at least ten
business days prior to the beginning of deleading. NOTIFICATIONS MAY BE FAXED.
1. Department of Labor 8 Industries, Division of Asbestos and Lead Enforcemnt
100 Cambridge Street, Room 1106, Boston, NA 02202 FAX: (617)727-7568
2. Director, Childhood Lead Poisoning Prevention Program aia.`i-%(lW0
Department of Public Health, 305 South Street, Jamaica Plain, MA 02130 FAX: (617) 188.6983
(617) 522-8735
3.
4.
5.
6.
Occl4ants of dwelling unit
All other occupants of the residential
Local Board of Health/Cede Enforcement
Massachusetts Historical Ccaission
220 Morrissey Blvd.
Boston, MA 02202
FAX: (617)727-5128
premises, if any
Agency
(if praises are listed on the State Register of Historic
Places, this notification asst be made upon receipt of an
Order To Correct Violations or at least 30 days prior to
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, ant-Lead Poisoning Prevention and Control
Regulations, 105 CMR 460.000, and that the information contained in this
notification is true and correct to the best of his/her knowledge and belief.
Date
1 - Signed '�°4 C• /1726.
Company Name t "V'.x C Vain,
Address: Ai cSs�tRbd h .\Z£'�`/1\C
t .\\t
Telephone Number: �lyt\b-DS l,- \ t
NOTIFICATIONS SHALL BE COMPLETED IN THEIR ENTIRETY, DATED AND SIGNED -
INCOMPLETE NOTIFICATIONS WILL NOT HS ACCEPTED AND WILL BE RETURNED BY D.L.I.