15 1st Floor Notification of Deleading 1992 DEPARTMENT OF PUBLIC HEALTH / DEPARTMENT OF LABOR & INDUSTRIES
NOTIFICATION OF DELEADING WORK
All sections of this form must be completed
notification requirements of NI.G.L.C. 111,197.
Contractor performing project:
Certification # : pC coil ifl
Lead Paint Inspector: SCo ff
Building Name:
Floor: 1st
Street Address: 15 Arr.o id AC t_
City: t\IDrth c. :.. o-Fcn M✓-a. ZIP: CAC Coo
Deleading Method: re „����, . rcpicctirnr.�'{—
Dwelling is: V�1 c�cc.._;r -t<l
Start Date: On or about 4 - - q2
Completion Date: On or about (` Z"7 - �Z
Work will be done during daylight hours. j
Project Supervisor: c2 4cr
Property Owner: b Alter.
In case of emergency contact:
In accordance with Chapter 773 of the Acts of 1987, Massachusetts General Laws
C. 111, 197, 454 CMR 22.00 and 105 CMR 460.000, notice of the date and method
of removal or covering of paint, plaster, soil or other accessible material con-
taining dangerous levels of lead, is to be provided to the following persons 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, NIA 02130.
4. Lead Removal Program, Bureau of Technical Services, Department of Labor
and Industries, Division of Industrial Safety, 100 Cambridge Street, Rm 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 Historical Places) .
The undersigned hereby states, under the penalties of perjury, that he/she has
read and understood the Commonwealth of Massachusetts Deleading Regulations,
454 CMR 22.00, and 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.
in order to comply with the
APR 231992
libmiumaucL
TOO Enterprises
10 Prospect Ave.
Greenfield, MA 01301
File #
Apt. #: ! R
Title:
Company:
Date: 4_ 18 _
�z
L7 L
TGC Enterprises
Tom Carter
10 Prospect Avenue
Greenfield, MA 01301
(413) 773-9225
DEPARTMENT OF PUBLIC HEALTH / DEPARTMENT OF LABOR & INDUSTRIES
NOTIFICATION OF DP'EADING WORK
All sections of this form must be completed in order to comply with the
notification requirements of M.G.L.C. 111,197.
File
TOG Enterprises
Contractor performing project: 10 Prospect Ave.
Certification : Greenfield, MA 01301
IJC co<1 eIT3
Lead Paint Inspector: tic if ljq l row r
Building Name:
Floor: I Si- Apt. # j R
Street Address: IS IA""oICa A c
City: NO *h a. °-i-c� , rv-A. ZIP: ( /c''. C .c,
Deleading Method: cc. C :cr, cr _ rnrc
Dwelling is:Start Date:Date: On or about 4 - 21— `72
Completion Date: On or about L -L'7 - y -
Work will be done during daylight hours.
Project Supervisor: —13 c� C ' ,
Property Owner: P. L, /3
In case of emergency contact:
In accordance with Chapter 773 of the Acts of 1987, Massachusetts General Laws
C. 111, 137, 454 CMR 22.00 and 105 CMR 460.000, notice of the date and method
of removal or covering of paint, plaster, soil or other accessible material con-
taining dangerous levels of lead, is to be provided to the following persons 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, Rm 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 Historical Places) .
The undersigned hereby states, under the penalties of perjury, that he/she has
read and understood the Commonwealth of Massachusetts Deleading Regulations,
454 CSIR 22.00, and Lead Poisoning Prevention and Control Regulations, 105 CJIR
460.000 and that the information contained in this notification is true and correct
to the best of his/her knowledge and belief.
Date:
Signed: o C
v rc
Title:
Company: TGC Enterprises
Tom Carter
10 Prospect Avenue
Greenfield, MA 01301
(413) 773-9225