38 Notification of Deleading 1994 In accordance with Chapter 717 of the Act] of 1987, Massachusetts Cer.crai Caws
C. 111 5197, 454 OMB 22.00 and 105 CMR 460.000, notice of the date and method(s) of
removal or covering of paint, plaster soil or other accessible material containing
dangerous levels of lead, is to be provided to the following persona at least five
days prior to the beginning of deleading.
1. , Occupants of the dwelling unit
2. All other occupants of the residential premises, if any
3. Director, Childhood Lead Poisoning Prevention-Program
Department of Public Health, 305 South Street, Jamaica plain, MA 02130
4. Lead Removal Program, Bureau of Technical Services
Department of Labor and-Industries, Division of Industrial Safety
100 Cambridge Street, Room 1101, Boston, MA 02202
5. Local Board of Health/Code Enforcement Agency
6. Massachusetts Historical Commission
(if premises is listed on the State Register of Historic Places)
The undersigned hereby states, under the penalties of perjury, that s/he has coed
and understood the Commonwealth of Massachusetts Deleading Regulations, 454 C.MR
22.00, and Lead.poisoning Prevention and Control Regulations, 105 R 460.00, and
that the information contained in this notification is trce and correct to the best
of his/her knowledge and belief.
Date ////o /91 Signed:
Title: ( j4-eiL76i
Companyf.Ja4-2 j- 72ro7.y4,4V 7,e/7/7: ("izOd //.,�/
Address rd/S�a/ri erJ/��/,2%,-O..U. , a,.../ i!/Jl�)4nii/?O/
Telephoneu
Office Use Only
THE COMMONWEALTH OF MASSACHUSETTS
DEPARTMENT OF LABOR AND INDUSTRIES
DIVISION OF INDUSTRIAL SAFETY
Too CAMBRIDGE SIRECT,AM. T/OT
LVi TON,MASSACHUSETTS 02202
0034u/6 rev 11/16/89
DEPARTMENT 0000GOLIC HEASTH/DSPARTMSNT or LAD;,^
NOTIFICATION OF DCLEADING WORK
All sections of this form must be completed in order to comply
the notification requirements of M.G.L. C. 111 5197
Pn(firr-
NOV 1 1994
th
/y d1 / FILE NUMBER
Lead paint Inspector Ie tZ e �, 4IL{Pv A Date of Inspection
Contractor performing projech,] 4,, ,z hcv/v„ec License •
Address of Project '�77 /
Building Name (if any) 3 /,�p�i„o Q ST
Street Address , d$ Ran-re # St
City 129. otryniC Zip /92'4
Deleading Method: DRY SCRAPING
(circle all that apply)
POWER SANDING
If 'Other' selected, please explain
Floor
Apt. No.
O /Otoo
/// 2/9/
DOo 76,5
Check one: dwelling is Multi-featly
Start date /7// 7/117
When will work be done: am R
single family
Completion Date /1/ 0 /fu
St weekends? 1
Y45
Project Supervisor Name Tir, F 6utin�cl License 1 000'74?
Property Owner ,/Qn/p,/ C/Kin s /
Ro
Address
City
Telephone
7-20.140 m/{o.7
ri/ S1 ys/a
State In74
Zip O/04o
In case of emergency, contact what person, /--
Phone: Area code required day 3 5A 7 £0S.k evening ti/3 Sad ROtia.
(OVER)
00348/5
rev 11/16/89