HomeMy WebLinkAboutSouth Main St. #147 apt.5 - 5/9/1996COMMONWEALTH OF MASSACHUSETTS
Department of Labor & Industries and Department of Public Health
NOTIFICATION OF DELEADING WORK
All sections of this form must be completed in order to comply
with the notification requirements of M.G.L. c.111 § 197,
454 CHR 22.00 and 105 CMR 460.000 as most recently amended
n IFILE NUMBER: (AGENCY USE)
perforrrm;. .,ecY. �-(J 11 teens iax2 SOC Z�}C �:rt r..ap �e//00oj0i
Exp.date 3lad/77
Lead Paint Inspector o.Q P �Vu f�[g n}lA License # R'a 1 6 q
Date of Inspection 0-1K•g5
If low -risk deleading work is being performed, complete the following line:
Property owner Agent(s)
Address of Project
Building Name (if any) Floor
Street Address J41
S. 1 Atli,) 3+ Apt. No. 5
city R t)S Qbe\ Y\Q Zip
Deleading Method: Wet/Dry Scraping Heat Gun Caustics
Liquid Encapsulant Covering Demolition Replacement Other
If "Other" selected, please, explain
Check One: dwelling is multi -family single �f^amily
Start date 5-�/ �( Completion date 5ZY,1�4
When will work be done: A.M. �P.M.
Weekends? f-)o
Project Supervisor's name t�-11�D uby VA License # Do Gas Ql
Property Owner A6,cG' Itc-�pe,f UICAOAt1, C0100jll
Address ) ISr) S tA,,a,
City, C. o State 11p Zip
Telephone ) 09-33 - 3(.4S ' L
In case of emergency contact
Phone: day LbS- Y9 I-33L(9 evening
(over)
In accordance with Massachusetts General Laws c. 111 3 197 CMR 22.00 and 105 CMR 460.000 notice
of the date and methods(s) of removal or covering of paint, plaster or other accessible materials
containing dangerous levels of lead is to be provided and must be received by the following
persons, at least tan (10) days prior to beginning of deleading.
1
2
3
5
M
Occupants of the dwelling unit
All other occupants of the residential premises, if any
Director, Childhood Leading Poisoning Prevention Program
Department of Public Health, 470 Atlantic Avenue, Boston, MA 02110
Director, Asbestos b. Lead Program
C eC:ar bic �.l _,` LaiJe C. {ndu ;t ri es
R,om It pl:e 04 aar-::ridge Street
Boston, NA 0:'202
Local Board of Health/Code Enforcement Agency
Massachusetts Historical Commission
220 Morrissey Blvd.
Boston, MA 02125
Deleading Contractor
Fax (617) 753-8436
Fax 1617) 72-t'568
(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)
Fax (617) 727-5128
The undersigned hereby states, under the pains and penalties of perjury, that
he/she has read and understood the Commonwealth of Massachusetts Deleading
Regulations, 454 CMR 22.00 and Leading Poisoning Prevention and Control
Regulations,' 105 CMR 460.000, and that the information contained in this
notification is true and correct to the best of his/her knowledge and belief.
Date Y.'_c)a_q(o... 'f e: Signed:
Title: riie6l Ce./tw ` (�
4'T
Company: Cz/ r_>C .6 i�z SSOC
Property Owner (If owner or unlicensed owner's agent will be performing low -risk deleading work)
I certify that I have complied with the training requirements of the
Commonwealth of Massachusetts Lead Poising Prevention and Control Regulations,
105 CMR 460.175,''toi owner/agent low -risk abatement and containment. I
further certify that I or my agent will be performing
the following low -risk activities (I have circled all that apply):
applying liquid encapsuIant lapping baseboards
applying exterior vinyl siding, covering surfaces
removinu doers, cabinet doors, shutters
I certify that all the information contained in this notifi,ation is true and correct to the
best of my knowledge and belief.
Gate:
t,igned;
REV 10/12/95