HomeMy WebLinkAboutChurch St. #32 apt.1 - 4/30/1998W Chi �)e i- C)g -13 Z-Ne)
Department of Public Health/Department of Labor & Workforce
4 Development
4
g NOTIFICATION OF DELEADING WORK
ti All sections of this form must be completed in order to comply with
the notification requirements of M.C.L.C. 111197
454 CMR 22.D0 and 105 CMR 460.000 as most recently amended
Contractor performing project Paint by Numbers of N.E.. Inc. License #D.C.000021 Exp. Date 02/11/09
Lead Paint Inspector Mel Blackman Date of Inspection 10/12/07 License Number M 1377
Address of Project:
Street Address: 32 Church Street, ant. 41
City: Mansfield State: MA Zip:02048
Property Owner. Al Noor Academy Address: P.O. Box 800, Mansfield, MA 02048
Telephone Number: 508-261-7077
De -leading Method <Wet/Dry Scraping Heat Gun capsulant
Demolition Caustics Replacement
Coverin Other
If other selected, please exp am: dipping
Cbeck One: Dwelling is multi -family X Single family ^ Other
StartDate: An0121, 2008 Completion Date: Aari130.2008
When will work be done: AM X PM X (specify times on site) Weekends
Project Supervisors Names
Worker's Compensation Policy Number WC7484197 Carrier American Home Assurance
In case of emergency, contact Anthony McLaughlin Telephone Number 508-824-0080
Deleadina 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
CMR 22.00, and the 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 Aoril 17.2008 Signed a ld ,U1
Company Name: Paint by Numbers of N.E., Inc.
Address: 18 Reed Street, Taunton, MA 02780
Telephone Number: 508-824-0080
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