HomeMy WebLinkAboutCentral St. #101 - 5/9/1996I
COMMONWEALTH OF MASSACHUSETTS
Department of Labor a industries and Department of Public Health .
NOTIFICATION OF DELEADING WORK
All wotloN of this form must he oosq:leted in order to comply
with the notification requirements of M.G.L. c.111 5 197,
656 Cat 22.00 and 105 Cat 460.000 as most recently amended
PILL MOOR: (AGENCY U9E)
Contractor Perfomtiny Pf*,t A�2 J�J I; Cvnf2�C�- mac( License # 2
Exp.date y/
20V License # M ^ 11L
Lead Paint Inspector Z✓I✓��vh,tn�� Lh/�
Date of Inspection 01-1-11-96
If low -risk doleading work is being performed, complete the following line:
Property owner Agent(s)
Address of Project
Building Name (if any)
Floor
Street Address �UL CFn//��L S/. Apt. No.
Zip OaO4, �
city /'Y/�.NsFc�/�
Deleeding Meth ry Scrapinq eat Gun Caust' s
Liquid Encapsulant. Covering Demolition Replaceme � Other
If "Other" selected, please explain
Check 011e1 dwelling is multi -family
single family
Start date �' a - q6 Completion date S' 9-y6
When will work -be done: A.M.
p.M. c,-'� Weekends?
Project Supervisor's name 4,(i�� ��✓�""-- License # 4 ,1
Property Owner - S C�c v✓lel
Address 2C7 529SL
City 191H,E%o�0 State !11 /9 Zip
Telephone d ' Z22- ZLL
In case of emergency contact
Phone: day S-Uq' Zz l- - Z41 L(S evening
(over)
d Io5
notice
In accordance with Massachusetts General Laws C. 111 S 197 laster0 or other accessible materials
materials
of the date and methods(al of removal or covering of paint, p the following
containing dangerous levels of lead is to be provided and must be received by
persons, at least ten (10) daVa Prior to beginning of deleading•
1. occupants of the dwelling unit
2. All other occupants, of the residential promises, if any
Y�.
3. Director, Childhood Leading Poisoning Prevention Program
Department of Public Health, 470 Atlantic Avenue, Boston, MA 02110
4. Director, Pro r
Department ofestos Labor6aLIndust rlesm
Room 11006, 100 Cambridge Street
Boston, MA 02202
5. Local.. Board of Health/Code Enforcement Agency
I. ,
6. Massachusetts Historical Commission
220 Boston, rMAs02ey Blvd 125.
Fax (617) 753-8436
Fax (617) 727-7568
(If premises is listed on the state Register
of Historic Places, this notification must be
made upon receipt of an order to Correct
.Violations or at least 30 days prior to
initiating preventive deleading) 727-5128
- n.lradinc Contractor_
The undersigned hereby states, under the pains and penalties of perjury, that
he/she has Regulationsre454and CMRu22B00tood the commonwealth of and Leading Poisoning preventionsand sControl
dinq
Regulations, 105 CMR 460.000, and that the information contained in this
notification 1a true and correct to the best of his/her knowledge an elief.
Date
Titles
Companyt411
-
Property owner (If owner or unlicensed owner's agent will be performing low -risk deleading work)
ining
rements
I certify that I h;sachusettsdLeadwith
poising aPreventionland control tRegulations#
Commonwealth„ to'f";4a
105 CMR,460.,11.5,I„for owner/agent low -risk abatement and containment.
further certify -that 1 activitlestwill (I haveeerformincircled all that apply):
the following 11
+u d,oncapsulant capping baseboards
applying liq }. -_ .
-- covering surfaces
applying exterior vinyl siding
r,emovinp doors, cabinet doors, shutters
I
I certify that 'all the Ofbeliefon contained in this notification is t nie and correct to the
bast of my knout}�,dg
Signed:
REV 10/12/95
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