36 Deleading Notification 2000 Department of Public Health/Department Of Labor & Industries
NOTIFICATION OF DELEADING WORK FILE NUMBER
All sections of this for mat be completed in order to comply with
the notification requirements of M G L C 111 § 197,
454 Om 22.00 and 105 DIR 460.000 as most recently amended
Contractor performing project \ `9V Ay\G A1/2b,.License #_.\` t3 Exp. DateA- -t \
Lead Paint Inspector )Ngg1P License # ld9.
PROPERTY OWNER (If owner or unlicensed owner's agent will be performing low-
risk deleading work, I ,
complete the followin g ): i ^ (j "e '-
Property Owner Agent(s)
Address (; DEC 8 Lu
Telephone Number INO-.: Am ----/
PtON
_- __--/
I certify that I have complied with the training requirements of the Commonwealth of Massachusetts Lead
Poisoning Prevention and Control Regulations, 105 OE 460.175, for over/agent low-risk abatement and
containment. 1 further certify that I or my agent will be performing the •-following low-risk activities (I
have circled all that apply):
applying liquid ercapsulant 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 ?">\0 S --\\-HGtQC a Apt. Number t c\
City ) VtA v x L'N Zip G\G\UG
PropertyOwner
Telephone Number\7") -
Address y\\ZC� kVt.
'IcA\si-r..^t-\ <CnA G\Go3
Deleading Method: Wet/Dry-Scraping Heat Gun Liquid Encapsulant
Demolition Caustics ll—eplarement�
Coveriig Other
If °Other" selected, please explain
Check one: dwelling is multi-family V single-family
other
Page 2 of 2
Start Date )a.-
Completion date\ & -W\'CC
When will work be done- am_ pm_ (Specify times on site) Weekends?
Project Supervisor Name )\(\C.
License#CC\`JteOz Exp. Datea.-�.�r-`✓\
Workman's Compensation Policy Number\ci..,C1rC\5C-.ab\S Carrier—Z.—\.1E\(�\
In Case of Emergency Contact:
Contractor's Representative)
In accordance with Massachusetts General Laws C. 111 4197, 454 CMR 22.00 and 105 CAR 460.000, notice of the
date and method(s) of removal or covering of paint, plaster or other accessible materials containing
dangerous levels of lead is to be provided and amt be received by the following persons, at least ten
business days prior to the beginning of defending. NOTIFICATIONS MAY BE FAXED.
1. Department of Labor 8 Industries, Division of Asbestos and Lead Enforcement
100 Cambridge Street, Room 1106, Boston, NA 02202 FAY: (617)727-7568
2. Director, Childhood Lead Poisoning Prevention Pr09ram a.0y- c"i-3e
Department of Public Health, 305 South Street, Jamaica Plain, MA 02130 FAX:61617) 03-� t
693
3. Occupants of dwelling unit at,-.\-. •tO%
4. All other occupants of the residential premises, if any
5. Local Board of Health/Code Enforcement
6. Massachusetts Historical Commission
220 Morrissey Blvd.
Boston, NA 02202
FAY: (617)727-5128
Agency
(if premises are listed on the State Register of Historic
Places, this notification mast be made upon receipt of an
Order To Correct Violations or at least 30 days prior to
initiating preventive defending)
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 CNR 22.00, sal-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/he r� knowledge and belief.
a.
Date V -\D-E%C Signed "�. ( - . n71719
Company Name:'Ht\t Q. N\ -
Address: Sr' `YCUS>40A-'-c\ CN�iF`'ti �C.r(�t�\ � k l \l—>31
Telephone Number: ^N3 -War\ -3\v.-)9,
NOTIFICATIONS SEAR BE COMPLETED IN THEIR ENTIRETY, DATED AND SIGNED -
INCOMPLETE NOTIFICATIONS WILL NOT BE ACCEPTED AND WILL BE RETURNED BY D.L.I.