HomeMy WebLinkAboutWest St. #17 - 9/10/201011 10 11:14a
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i Department of Public Health/Department of Labor & Workforce
Development
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NOTIFICATION OF DELEADING WORK
All sections of this form must be completed in order to comply with
the notification requirements of M.C.L.C. 111 197
454 CMR 22.00 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 02l24/11
Lead Paint Inspector Paula Prior Date of Inspection 05/3/10 License Number 3985
Address of Protect:
Street Address: 17 West Street
City: Mansfield State: MA Zip:02048
Property Owner: Orthodoxcongregational Church Address: same as above
Telephone Number: Rob Franklin 781-297-2319
De -leading Metho�t/Dry Scraping Heat Gun Liquid Encapsulant
Demolition Caustics Re lacemen
overin Other
If other selected, p ease explain: dipping
Check One: Dwelling is multi -family Single family _ Other_X_
Start Date: August 21, 2010 Completion Date: _September 10, 2010
When will work be done: AM X PM X (specify times on site) Weekends
Project Supervisors Names: Mike Bushe License # DS3413 Exp. Date 1/10/11
Arnold Thomas License # DS000854 Exp. Date 9/24/10
Worker's Compensation Policy Number LB-0767N286-09 Carrier Travelers
In case of emergency, contact Anthony McLaughlin Telephone Number 508-930-0905
Deleading 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 CNIR
460.000, and that the informatio o ined in this notification is true and correct to the
best of his/her knowledge an elief jn �/�
Date Aug.11, 2010 Si*ei�
Company Name: Paint by Numbers of N.E.. Inc.
Address: 1S Reed Street, Taunton, MA 02780
Telephone Number: 508-824-0080