103 Notification of Deleading 2000 Departs
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of Public Health/Department Of Labor & Inet‘:es
NOTIFICATION OF DELEADING WORK FILE NUMBER
All sections of this form oust be completed in order to comply with
the notification requirements of M.G.L.C. 111 4 197,
454 OIR 22.00 and 105 CMR 460.000 as most recently amended
.ntractor performing projectu¢ License its..WC1 Exp. Date-t-p\
li���� eXtatt-e License I t4'. M.
ad Paint Inspector 1'1s't'nP
tOPERTT OWNER (If owner or unlicensed owner's agent will be performing l_.r__- �
.sk deleading work, LS 6
:omplete the following ): a I Ames i au I
roperty Owner Agent(s)
)dress
alephone Number N
certify that I have cceplied with the training requirements of the Caom.awealth of Massachusetts Lead
limning Prevention and Control Regulative, 105 out 460.175, for owner/agent low-risk abatement and
ntaireent. I further certify that I or my agent will be performing the •-following low-risk activities CI
lye circled all that apply):
plying liquid encapsulant capping baseboards removing doors, cabinet doors, shutters
plying exterior vinyl siding covering surfaces
certify that all the inforsation contained In this notification is-true and-correct to the best of my
nowledge and belief.
ate: signed:
ORTNANPImN EOAIIp OF NEkIIH
1DDRESS OF PROJECT:
ttreet Address 10� ���� c-SCep41(
Apt. Number
:ity
?ropertyOwner
Zip O\ ■bb
Address `y-
�1o \ca��� 0\Ob
telephone Number 4-1/2s,Th-ctvit5-a `za
Heat Gun Li• id E.ca•-ulant
Deleading Method: Wet/Dry Scraping Caustics placement
Demolition Other
Covering
If "Other" selected, please explain
Check one:
dwelling is multi-family single-family
other
Page 2 of 2
Start Date -\' -GC Completion date -\\O-Ct?
When will work be done: �1am 1��t(`, pml�'1X`{SSpecify times on site) Weekends? r(�
Project Supervisor Name a 4?tt Q.t'&» . License#'.\441 Exp. Datea_a%-0\
Workman's Compensation Policy``Number`%. ti:f\i?\.S.aoab\� Carrier Z.'as c\x
In Case of Emergency Contact: .]tt.rSnT _1 t (Contractor's Representative)
'i\-'-Val-�\\o%
In accordance with Massachusetts General Laws C. 111 1197, 454 ON 22.00 and 105 DIR 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 era) mat be received by the following persons, at least ten
business days prior to the beginning of deleadine. NOTIFICATIONS MAY BE FAXED.
1. Department of Labor 6 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) 9ei-4919 a6Yp-53'' 48b
(617) 522-8735 aP_)4 -$4CCl)
3. Occupants of dwelling unit
4. All other occupants of the residential premises, if any
5. Local Board of Health/code Enforcement Agency
6. Massachusetts Historical Camissia (if premises are listed on the State Register of Historic
220 Morrissey Blvd. Places, this notification met be made ipon receipt of an
Boston, MA 02202 Order To Correct Violations or at least 30 days prior to
FAX: (617)727-5128 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 CIR 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
Company Name: ` . NellO
Address:
Telephone Number:
Signed
e ,115.4e,
NOTIFICATIONS SHALL BE COMPLETED It ;HEIR ENTIRETY, DATED AND STONED -
INCOMPLETE NOTIFICATIONS WILL NOT SIN ACCEPTED AND WILL BE RETURNED BY D.L.I.