22 Notification of Deleading 1997 ofthe date and methods(sl r emoval or c ov ring of paint, plaster e h f r,= _o
containing dangerous levels of lead is to provided and must be received by th` fr lc.
persons, at least ten (10) days prior to beginning of deleading.
1. Occupants of the dwelling unit
All ether occupants of the residential premises, if any
Director, Childhood Leading Poisoning Prevention Program
Department of Puplic Health, 470 Atlantic Avenue, Boston, MA 02110
4. Director, Asbestos & Lead Program
Department of Labor r Industries
Room 1100e, 100 Cambridge Street
Boston, MA 02202
5. Local Board of Health/Code Enforcement Agency
Massachusetts Historical Commission
220 Morrissey Blvd.
Bostnn, MA 02125
Deleading Contractor
Fax 1617) 753-&4
tax (611) 727-7568
(If premises is 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)
Fax ..6171 /27-5122
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 CMR 460.000, and that the information contained in this
notification is true and correct to the best of his/her knoy}edge and belief.
Date /O/ 5'O / 97
Signed:
LJr1 /1 .
Title: DELEADING CONTRACTOR/OWNER OF
company:RemlaP LEAD PAINT REMOVAL CO. , INC.
Property Owner (If owner ur unlicensed owner's agent will be performing low-rise deleading work)
I certify that I have complied with the training requirements of the
Commonwealth 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 ligr.;d en-ap,ulant
ap,lyind .. ter . n vinyl siding
remrving doors, dour_, shutters
I certify that ali rLe ird nmarton contained in this notlfi
Sigrmd:
REV 10/1'/n(
capping baseboards
covering sullau_
S)MMONWEALTH OF MASSACH"ET TS _
p
Department of Labor a Industries and Department of Pil, r-y �1 �{A .0...M r.:
NOTIFICATION OF DELEADING WORK 31997
All sections of this for must be completed in order to comp y
with the notification requirements of M.O.l. 0.111 5 197, -
454 am 22.00 and 105 045460.000 as most recently amended,-
FILE NUMBER: (AGENCY USE)
Contractor performing project THOMAS E. PALMER licensee DC 001077
Exp.date04-28-98
Lead Paint Inspector PETER MILLER License 4 IR2808
Date of Inspection09-20-97
If low-risk deleading work is being performed, complete the following line:
Property owner Agent (s)
Address of Project
Building Name (if any)
Street Address 22 WESTERN AVENUE
City NORTHAMPTON, MA yip 01060
Floor
Apt. No.
Deleading Method: Wet Dry Scraping)
Heat Gun Caustics
Liquid Encapsulant cisiverin) Demolition Ceplacementl Other
If "Other" selected, please explain ��
Clerk One:
Start date
dwelling is multi-(amity single family xx
NOVEMBER 15, 1997
Completion date
NOVEMBER 22, 1997
When will work be done: A.M. XX P.M. XX Weekends? YES
Project Supervisor's name
N/A License N
Property Owner SCOTT BRODEUR
Address 22 WESTERN AVENUE
City NORTHAMPTON
Telephone (WORK) 201 -459-2806
In case of emergency contact
Phone: day 413-731-6666
State
MA
WILLIE MAE ARCHIBONG
Zip 01060
evening
(over)
413-736-3287