HomeMy WebLinkAboutFruit St. #358 - 7/11/1997.SUN-09-97 MON 09:03 AM STRAIGHTLINE DELEADING P_01
�} Department of Public Health/Department of Labor & Industries
: NOTIFICATION OF DELEADINO WORK
All sections of this form must be completed in order to comply with
the notifioatioo requirements of M.O-L. C. I I I § 19?,
454 CMR 22.00 and 105 CMR 460.000, as most recently amended
Contractor performing project A/I ✓i d �:Z,!2-4al/a/Z_Licenso M,6a (5_1,�xp. DateA lQ���9> .4
Lead Paint inspector_ld'a,, Xl " _License N 1. Z4Z4
PROPERTY OWNER (If owner or unlicensed owner's agent will be performing lovwrisk deleading work, complete the following):
Property
Telephone Niunber_
t unify that I have oomplled with the training requirements of the Commonwealth of Massachusetts Lead Poisoning Prevention and Control
Regulations, 105 CMR 460.175, for owrtedagent low -risk abatement and containment. I further certify that I or my agent will be performing the
following low -risk activities 0 have circled all that apply): '
applying Gquid encapsulant capping baseboards removing doors, cabinet doors, shuhcn
applying exterior vinyl siding coveting surfaces
I certify that all the information contained in this notification is true and correct to the best of my knowledge and belief.
Date Siened
A.D'DREss of PRo.7ECT:
Street Address _2azl. 4_y mom. ..--Apt. Number 41L_—_ Y
City'A&R Zip 7
Property Ownerjo-re h; j��y �Yd� /, Address ' ) �__ ___ ___
Telephone Number
7�-a IVO, �C�5jZOr/, l%�% 4ia,35y
Dalrad ng Method: ['CVeUDry So
Heat Gun Liquid Encapsulant
emo ttlon Caustics Replacement
Covering Other
If"Other' selected, please explain —
Check one. Dwelling is multi -family Single-family__
JUN-09-97 MON 08:04 AM STRAIGHTLINE DELEADING P.02
Page 2 of 2
Stott Date - Completion Date i 4
,r
When will work be done: am pm� (Specify lots on site.) Weekends') j!
Project Supervisor Name i /I -F/d Si37C/ i? License NQ�D Of 3tp. Date�j'7.�"�_
Worker's Compensation Policy Number -a �i X 7 % _Carrier�x� ✓P��� 7�
In case of emergency contact ,61 yLd Ai:5& a 17 (Contractor's Represeritative)
Tn a"ordancc with Massachusetts Goneral laws C. I I §197, 454 CMR22.00 and 105 CMR 460,000, notice of oho dale and method(s) of removal
or covering of paint, plastor or Odle( aecessibte materials wntaining dangerous levels of lead islo be pfovidod and must be received by the following
agencies, at least TEN days prior to the beginning ofdetcading. NOTIFICATIONS MAYBE FAXED.
1. Department of Labor & Industries, Division of AsbestoslLead Licensing and Enforcement
100 Cambridge, Street, Room 1106, Boston, MA 02202 FAX (617) 727-7568
2. Director, Childhood Lead Poisoning Prevention Program
Department of Public Health, 470 Atlantic Ave., Boston}, MA 02111 FAX (617)753-8436
3. Occupants of dwelling unit
4. All other occupants of the residential premises, if any
S. Local Board of Health/Code Enforcement Agency
6. ..Massaohuscttss Historical Commission
220 Morissey Blvd.
Boston, MA 02202
FAX (617) 727-5128
DELEADING CONTR.A.CTOR
(if premises are listed on the State Register of Pstoric
Places, this notification must be made upon receipt of an
Order to Correct Violations or at least 30 days prior to
initiating preventive dcleading)
The undersigned hereby states, under the pains and penalties of perjury, that lielshe has read and understood the L'ommonwealtll of
Massachusetts Deleading Regulations, 454 CM 22,00, and the Lead Poisoning Prevention and Control Regulations, 105 CMR
460.000, and that the information contained in this notification is true andd^J,coorreect to the best of his/her knowledge and belief
Dale.7,!/7r_? /%�,' %99% Signed &fj/
NOTIFICATIONS SHALL BE COMPLET9D IN THEIR ENTIRETY, DATED AND SIGNED - INCOMPLETE
j OTIFIC.ATIONS WILL NOT BE ACCEPTED AND WILL BE RETURNED BY D.L.T.
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