HomeMy WebLinkAboutWare St. #171 apt.1 - 12/7/2004Deleading Notification
sections of this form clearly. Incomplete or illegible forms will be returned.
Please complete all s t//ons y P g
Lead Paint Inspector C AYLl s`L.,2"( !/�� GC License # j/ 260(, Inspection Date 3 �S
Property Owner /�-Onc��t (-41,r)r /6 L-L� /
Property Owner's Address /9S' C c b. S/n i�S iC" Sr E/,&4ai vU14 S 5 Zip Code n 23-Y(o
Authorized person performing work: 1Z al 0 -_ Lie#/Auth.# O a Z'/3 -U
Address of authorized person ! fir 5 LAJ Gas sS Zip Code C� z SG
Telephone Number (106 'Z5k-67S,0
Address where the work will be done:
Building Name (if any) Floor itLST
Street Address / -7/ t cJ41 e ST Apt No.
City jZY 3 � Fc-e 1 Zip Code 6 7-VO The property is a multi -family _ single family.
Deleadine Method(s):
❑
Making paint intact (high risk) ❑
Making paint intact (moderate
❑ Applying vinyl siding on
❑
Demolition
risk)
❑ Component removal (low
❑
Scraping o
Liquid encapsulant
components)
X
Component removal/replacement X
Covering
❑ Other:
❑
Dipping ❑
Capping baseboards
The work will begin on L/ Z / 6 and will finish by _/ / . The work be done in the
1/am _pm or _weekend:
1-7-�
In Case of Emergency
Daytime Phone .505
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 Lead Poiso
Prevention and Control Regulations, 105 CMR 460.000, will conduct deleading work. I further certify that the authorizes
person(s) will not exceed the scope of his/her authority and will be perfogning only those activities indicated above. All
information contained in this document is true and corre to t e best o in knowledge'and belief.
Date '1'z O U Signed
The following people/agencies must be notified ten days before beginning work:
I. 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 Reeister of Historic Places. call the MA Historical Commission at (617) 727-8470.