70 Notification of Deleading 1997)cl997 10-O4AM FROM ABIDE INC
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4132470245 P. 2
COMMONWEALTH OF MASSACHUSETTS
(-97(Y
i r
Department of Labor 6 Industries and Department of Public Health
JUN I21997
NOTIFICATION OF DELEADINC WORX
All sections of this term muse if oospleted in order to avally
with the ratification req'iresenti of N.O.L. c.111 S 197,
454 a4a 22.00 and 105 CHR 660.000 as most recently amended
(AG@1CY Use)
Contractor perionning pryect CW)1 t Q TC C P/ AO C.11 it.1 1 License e DC Uo t 17 K
Exp.date j6( )L i /919-
Lead Paint Inspector }( h zQri A .54mini License if 1"1- /72.10
Date of Inspection icJ am I
If low-risk deleading work is being performed, complete the following line:
Property owner Agent(s)
Address of Project "�
Building Name (if any)r nnfd5/d A1-t(Q(e. Floor 'S-4 2, (a(1(ta be
Street Address CIO PQ(. (11se - Apt. No
ZiP O/Dto
City Abn_ ho Imo-Inn) AAA-
Deleading Method: Wet/Dry Scrapin Heat Gun Caustics
Liquid Encapsulant Demolition Replacement Other
If "Other" selected, ple
e explain
Check On%: dwelling is vault i-family /V f1F single family
Start date
t. (aulq�—
When will work be done A fl-
r7
Completion date 2/1/ rS 9—
P.M. S"7)in weekends?
Project Supervisor's name { l(e F-Clp Li
Property Owner /," r 1I^rr ' GCoI L 3-
Address J Mann tL/e.
City On�(j/-/r-rm,( nn 1'� State !L' A- zip 6 %Q�p
Telephone "'j f.3
In Case of emergency contact j/(q (1 �' i 1 � )
qi
License d ) -OCFa
Phone: day
- L3 535 Cato UH evening 4t.3 sass- 015
:over)
1997 10,04AM FROM ABIDE INC 413247924E P. 3
In accordance with Massachusetts General Laws c. 111 4 19: CMR 22.00 and 105 04R 460.000 notice
of the date ina methods(s) of removal or covering of paint; plaster or other accessible material,
Containing dangerous levels of lead is to be provided and must be received by the following
persons, at least teen (10) days prior to beginning of dele9dlnq.
1. Occupants of the dwelling unit
2. All other occupants of the residential premises, if any
Directory Childhood Leading Poisoning Prevention Program to (611) 753-8436
Department of Public.Health, 470 Atlantic Avenue, Boston, MA 02110
4. Director, Asbestos 4 Lead Progtant
Department of Labor 4 Industries
Room'11006,_ 100 Cambridge Street
Boston. MA 02202
s Local board of Health/Code Enforcement Agency
6. Massachusetts Historical Cemmissron
220 Morrissey Blvd.
Boston, MA 02125
Deaea8.nq Contractor
Fax (611) 721-'1S66
(417-I'?).
cY/3)
Peti tit&Qr I*i A} 5`6(4 393(.9
6f 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 deleadirp) '
Fax (6171 727-5120
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 +est of his/her knowledge and belief.
Date
Sign
Title: -Dl ,( 61- reof SKP,o/2 - /E
Gem: any:
Property Owner Of owner or unlicensed owner's agent will be performing low-risk deleading wotkq
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 liquid encapsul ant
aPplying exterior vinyl siding
tepoving doors, cabinet duces, stuttois
at all the infOrmaiien -wtta:ned in t
nwledge ar.0 belief.
Data: `'IglanD
MEV 50!12/95
capping baseboards
covering surfaces
notarisation Is nue and correct to in.