26 Deleading Notification 2000 Department of Public wealth/Department Of Labor B Industries
rN@IIIW
! SEP 191000
NOTIFICATION OF DELEADING WORK FIL3 NU BUR
All sections of this form must be completed in order to comply with
the notification requirements of M.G.L.C. 111 4 197,
454 CMR 22.00 and 105 OW 460.000 as most recently amended
eTh
11
NORTHAMPTON BOARD OF HEAUN
Contractor performing
lI��project VCck:NC\S6 License i NAWA.Exp. Date
Lead Paint Inspector T\S`6P C 5nQ'\ PSQ. License I NXt%14:`k
PROPERTY OWNER (If owner or unlicensed owner's agent will be performing low-
risk deleading work,
complete the following ):
Property Owner Agent(s)
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 CMR 460.175, for owner/agent low-risk abatement and _
containment. 1 further certify that 1 or my agent will be performing the i-following low-risk activities Cl
have circled all that apply):
applying liquid encapsulant capping baseboards removing doors, cabinet doors, shutters
applying exterior vinyl siding covering surfaces
1 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 NOZCcrr`�
Aptamwecit∎ C
Zip �:‘\ \' 3c
Propertyowner'��y(� �� � Address ab `-tzd mil\\\t
Telephone Number --\' S- 5c .. rJ-^.aat'S .
Deleading Method: Wet D Scraping Heat Gun L' nca sulant
�:Tfl7: on Caustics replacement
Other
If "other" selected, please explain
Check one:
dwelling is multi-family V single-family
other
-Page 2 of 2
Start Date S- alc\-C(.> Completion date \C1) --3-C3C)
When will work be done: am
pm (Specify times on site) Weekends? \lC
Project Supervisor Name \ `RV\FCC_NycoN, LicensefVi..\`\tip Exp. Date .-aN-O\
Workman's Compensation Policy Number-1C\e' ,�% % t \g Carrier? S'\L\\
In Case of Emergency Contact: v,tN (Contractor's Representative)
\� Sa t-t\b6
In accordance with Massachusetts General Laws C. 111 §197, 454 CAR 22.00 and 105 CPR 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 mist be received by the following persons at least ten
business days prior to the beginning of deleading. NOTIFICATIONS MAY BE FAXLD.
Department of Labor L Industries, Division of Asbestos and Lead Enforcement
100 Cambridge Street, Roca 1106, Boston, MA 02202 FAX: (617)727-7568
Director, Childhood Lead Poisoning Prevention Program
Department of Public Health, 305 South Street, Jamaica Plain, MA 02130 FAX: (617) 963693;a%.i-% &o
3. Occupants of dwelling unit (617) 522-eF35. a%`..\-.. BV��
4. All other occupants of the residential premises, if any
5. Local Board of Health/Code Enforcement Agency
Massachusetts Historical Commission
220 Morrissey Blvd.
Boston, MA 02202
FAX: (617)727-5128
Of premises are listed on the State Register of Historic
Places, this notification must be made upon receipt of an
Order To Correct Violations or at least 30 days prior to
initiating preventive deleading)
DELEADINO 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 OAR 22.00, antl-Lead Poisoning Prevention and Control
Regulations, 105 CAR 460.000, and that the information contained in this
notification is true and correct to the best of his/her knowledge and belief.
Signed ' /C r_
Date
Company Name: \ -E'NI\'(\ C - • er\tCCa
Address: :1C) , \\N
a (":\l1`�.7
Telephone Number: 1'\\Z -
NOTIFICATIONS SHALL BE COMPLETED IN THEIR ENTIRETY, DATED AND SIGNED -
INCOMPLETE NOTIFICATIONS WILL NOT BE ACCEPTED AND WILL BE RETURNED BY D.L.I.
tl%LLZUUU {nu Li:uO inn Yla ac
•
RE VI S4 c**t
ABIDE, INC. PROJECT # (B7.13%
COMMONWEALTH OF MASSACHUSETTS
Department of Labor r Industries and Department of Public Benith
NOTIFICATION OF DELEADING WORE
All martiona or this tors wee no cooploeed in order to cooyzy
with the notification requirement, of M.O.L. e.111 5 197.
04 CMS 22.00 and 105 Q01 460.000 as meet recently amended
Fill )U R: CWZWCY USE)
Cnntractorperfonnlg project ABIDE, INC. (Frank Tilli)
license # D0001619
exp.date August 31, 20c1
Lead Paint Inspector App (ON,nei Ct )CM; et-� License N/1.127'21{
Date of Inspection MN/00
If low-risk deleading work is being performed, complete the following line:
Property owner Agentls)
Address or Project
Building Name (if any) ,t / Floor
s-
Street Address 22 Cot+nnews AvEAIQC. Apt. No.
city NUKTIAMPTON Zip oto6,f
Deleading Method: ([Jet/Dry Scraping) Heat Gun Caustics
Liquid Encapsulant prering Demolition Other
If "Other" selected, please explain
Check One: Welling IS 4 ti-[amily single tam,iy
start date
101 a!op
Completion dare
1U O
1013, Woo
when will work be done: A.M. J',N — P.M. 5: ()O weekends? no
Project Supervisor's name Robert P. LaHountain License If DS3605
Properly Owner B4,.0 S(HNkR,12. 041i 30EL FELDn1AA1 •
Address t1% AdumROf. SKEET
city NoR-Th,4MP NJ
Telephone _,.413- 5810 - 11 / 3
State
MA
In case of emergency contact Frank T1111, President
Phone: day 413-525-0644
_ zap OLO_GD-
evening 413-525-0644
(over)
In accordance with Masa.Cllusetta General Lava c. 111 5 197 OR 22.0U and 105 CM 460.000 notice
of the date and methods(s) of removal oe covering of paint, plaster or othir accessible mterial:
o
containing dangerous levels of lead to to be provided and must be received by the following
persons, at least ten (10) days prior to beginning of deleading, a
1. Occupants of the dwelling unit
2. All other occupants of the residential premises, if any
Director, Childhood Leading Poisoning Prayanclm Program FAX 1611) 753.0436
Department of Public Health, 110 Atlantic Avenue, Boston, MA 02110
Director, Asbestos 6 Lead Program
Department of Labor A Industises
Room 11006, 100 Cambridge Street
Boston MA 02202
Fax 1617) 127-7560
I*M[41 Ei 587- R21
Local Board of Health/code Enforcement A Agency
PTt Clans C✓F HfALTl�
NURT1iAM PI'0
Massachusetts Historical Commission
220 Morrissey Blvd.
Boston, MA 02125
Deleading Contractor
(It premises is listed on the State Register
of Bistorie Places, this notification must be
made upon receipt of an Order to Correct
Violations or at least 30 days prior to
initiating preventive deleadino)
Fax [b111 727■512B
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 and Leading Poisoning Prevention and Control
Regulations, 105 CAR 460.000, and that the information contained in this
notification is true and correct to the best of his/her knowledge and belief.
Date q -I -00 signea:
r
IS It'll Title:
�.al.enk,4i�i
IaS
President
Frank T111 i
company: ABIDE, INC.
Property Owner (If owner er unlicensed owngr', agent will be performing low-risk delesdjng work)
I certify that I have complied with the training requirements of the
Connonwealth of Massachusetts Lead Poising Prevention and Control Regulations,
105 CMR 460.175, for owner/agent low-risk abatement and containment. I
further certify that I or my agent will be performing
the following low-risk activities (I have circled all that apply] :
applying liquid encapsul ant
applying exre riot vinyl tiding
removing doors, Cabinet &e rs. Shutters
Capping baseboards
covering su,faces
I certify that all the information Contained in this notification Is true and correct to tee
best of my knwled9!' and belief.
Data: Stun
REV 10/12/95
ABIDE, INC. PROJECT # 003gc7