HomeMy WebLinkAboutChurch St. #23 - 10/18/2003Aug 07 03 02:27p
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Department of Public Health - Childhood Lead Poisoning Prevention Program
Deleading Notification
Please complete all sections of this form clearly. Incomplete or illegible forms will be returned., r
Lead Paint Inspector(-L U rt'a 0 '"e _ License 4 M 1 /0 Inspection Date j a 63
Property Owner K WA 14 1'r 1 O r
Property Owner's Address02 `. 3 (.hUf(�H Qn,5fje jj Mil Zip Code any
Authorized person performing; work: Pau l A 'Boor O( _ Lief!/Auth.# 6q I5 3s--6
Address of authorized person_ 5J3 Cj3jjrCAx a ry I a r S Zip Code
Telephone Number&BAN'1141
Address where the work will be done:
Building Name (if any) Floor
Street Address of U ' 115 IE M w Apt No.
City f i119-N_ Sp1 _Zip Code OaDU �l The property is a ✓multi family _single family.
Deleadinl Methods
❑ Making paint intact (high risk) ❑ Making paint intact (moderate ❑ Applying vinyl siding on exterior
❑ Demolition risk) ❑ Component removal (low risk
❑ Scraping ❑ Liquid encapsulant components)
Component removal/replacernent o Covering ❑ Other: _
Y� Dipping ❑ Capping baseboards
The work will begin on I/J �i/DOand wilt finish by 1a/I U0 The work be done in the ✓ am .�4m or— weekends
In Case of
Daytime 11
Evening
The Property Owner must complete and sign the following information:
1603
I certify that only authorized pera,ons who have complied with the training requirements of the Massachusetts Lead Poisoning
Prevention and Control Regulations, 105 CMR 460.000, will conduct deleading work. I further certify that the authorized
person(s) will not exceed the scope of his/her authority and will be performing only those activities indicated above. All of the
information contained in this document is true and correct to the best of my knowledge and belief.
Date�r`GN.3 Signed_��
The following people/agencies must be notified ten days before beginning work:
l . Occupants of the dwelling unit
2.- All other occupants of the residential premises, if any work will be done in the common areas �}
3. Childhood Lead Poisoning Prevention Program, DPH Fax (617) 284-8436
56 Roland St., Boston, MA 02129-1235
4. Asbestos and Lead Program, DLWD ,p3
399 Washington St., Boston, MA 02108 Fax (617) 727-7568,t�
S. Local Board of Health/Code Enforcement Agency �'�l cl°i
1- 508-db1-130
*If the home is on the State Register of Historic Places, call the MA Historical Commission at (617) 727-8470,