HomeMy WebLinkAboutPratt St. #108 apt.1&2 - 6/24/1996COMMONWEALTH OF MASSACHUSETTS
Department of Labor i Industries and Department of Public Health
NOTIFICATION OF DELEADING WORK '•
r
All sections of this fore: must be completed in order to comply
W with the notification requirements of M.U.L. c.111 S 197,
y 666 Oat 22.00 and 105 Cat 460.000 as most tooently amended
. �n. f1LE tmmumit: (AGENCY USE)
Contractor pedonnkp projsd f�,2 519FE l�o _License # OC 00c3 3u/
V Exp.date Gl-- 7—F6
Lead Paint Inspector d2oh.62A /% //o✓cZ ( License # 10 / 0
Date of Inspection 4_.a 3_ V6
If low -risk deleading work is being performed, complete the following line:
Property owner _ Agent(s)
Address of Project
Building Names .(if any) Floor
Street Address f09 1029%` S� Apt, No.
City %%%9NSfc' zip
Deleadinq Itetliod et/Dry Scra • Heat Gun Caustics
Liquid Encapsulant.: Covering Demolition Replaceme Other
If "Other" selected,'pleass explain
Check Onei dwelling is multi -family v single family
Start date �O Completion date 4— (16
When will work be done: A.M.
� P.M. �� Weekends? /✓
Project Supervisor's name ��f�1o*??_0 y7o License # !/S C009'c/3
Property Owner
Address
city / ✓/ZQn/�%r `9VY-7 State /?69SS zip OeO
Telephone 3F4- 29,�4
In case of emergency contact
Phone: day 4/145" evening
(over)
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In accordance with Masaachusetts General Laws c. ill S 197 CMR 22.00 and 105 the followinteria
containof the ing Bate and mouaolevela of removal
lead r cbeapr videdOf pand t mustbe received ebya them Bible materials
peraonb, at least to SO da • rior to beginning of deleading.
�..
1, occupants of the dwell,iy$ip.,.unit,.�
2 A11 or her occupants, of the residential.. promised, if any
3. Director,Childhood Leading Poisoning Prevention Program Fax (617) 753-0436
De" t"'hi'of Public Health,, 410 Atlantic Avenue, Boston, MA 02110
t p .r, 1 ..
r `. Fax (617) 727-7568
oLaa.Labo.r&a4Indooqqustri48m .
R om 11066, 100 Cambridge Street
Mk,02207,
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5 )tta,} 6,Qar�d of HM2h/Cod} &ntorwrwn4 Agency
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' * '(If premises is listed on the state Register
6. Massachusetts Historical Commission of Historic Places, this notification must be
20 Xgrrisseyy Blvd. made upon receipt of an Order toCorrect
to
Boston, HA 02125 .Violations or at least 30 days p
initiating preventive dFax (617) 727-5128
Deleay`; y,� Coetraotor ..
The unders�i_gned hereby states, under the pains and penalties of perjury, that
Delea
he/she has Massachu
Regulationare454aCMR 22e00tand Leading Poisoning PreventionsandsControding
notification is true and correct to the best of his/her knowledge and bel
Regulations, 105 CMR 460.000, and that the information containedAe a this
Slgnedt
Data,
Title$ �C�7iG
-r company$
''hl 1 fn4 p_
f
prno.rty low -risk deleadlnq work)
Qwner (if or unlicensed owner's agent will be performing
requirements of the
I certify tha I have complied with the training
Commonwealth ,Mdsetchusetts Lead Poising Prevention and Control Regulations,
1Q5 CMR 460.,15, !or owner/agent low -risk abatement and containment. I
further dertilp that I:or my agent will be �lerforM apply):
the.'followinq lOw-rla activities (I have circled all that
capping baseboards
agpiY,lnd 111400.orcapsulsnt _ - --
f
covering surfaces
�,eQplyin�akt�arior vinyl siding
d0oe�., cabinet doors, ahuttara
I ice to the
1F,'i•,ythat all the information contained in this notification is true and correct
bagtfof�tknowj�pe_ rnd Wlot.
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