HomeMy WebLinkAboutUnion St. #110 apt.2 - 2/28/2003Deleading Notification
Please complete all sections of this form clearly. Incomplete or illegible forms will be returned.
Lead Paint Inspector d AC -LC E- License # M 9/ yW Inspection Da� ® / V
Property Owner f-JBYEW Af cfiLI-N ! ,'(-
Property Owner's Address • ® • Q o yc Z*1 4 4/.f r/ Zip
Authorized person performing work: /-d! �i P �`/ ✓ f/� Licit/Ruth
Address of authorized person o • d q o d??A iJyfFi ew. vim. A
Telephone Number
Address where the work will be done:
Floor 91V
Building Name (if any)
Street Address / / m V n/ i ® .N S T Apt No.
CityNJ/ s c U Zip Code f}2oV fr The property is a ✓multi famih
sitiele family.
Deleading Method(s):
❑
Making paint intact (high risk)
Making paint intact (moderate ❑
Applying vinyl si
❑
Demolition
risk) ❑
Component remo
❑
Scraping
❑
Liquid encapsulant
components)
,,W
Component removaUreplacement
)'
Covering ❑
Other:
❑
Dipping
N(
Capping baseboards
P on e)
(low ri
The work will begin on < /31/ v4nd will finish Ify J 013The work be done in the )K am X pm or _ wgekends.
In Case of
Daytime P
Evening
The Property Owner must complete and sign the following information:
I certify that only authorized persons who have complied with the training requirements of the Massachusetts Lea' Poisonii
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
information contained in this document is true and correct to the best of my knowledge' and belief
Date ! zii� �n 3 Signed_/�l iv�jd %2
The following people/agencies must be notified ten days before beginning work:
1. 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
399 Washington St., Boston, MA 02108 Fax (617) 727-7568
5. Local Board of Health/Code Enforcement Agency
° If the home is on the State Register of Historic Places. call the MA Historical Commission at (617) 727-9470.