HomeMy WebLinkAboutWest St. #43 - 10/6/1994ASPARTANNT OF PUBLIC HEALTH/DEPARTNBNT OF LABOR i INDU5rRl3S
NOTIFICAT.rOM Cr DBu"Doc AORx
All sartions of this fora Must be cveplated in order to ocrply with
the notification repuiremants of Y.C.L. C. 111 §197
n IPILz NUNBLR
Contractor performing pro lace 2/ �� /-( 0�1//4Ch< Certification I C CSCy03U✓
Lead Paint Inapectot L�q(,(' �i�.�/' %n �ec� Drte of Inspectluo
Address of Project
Building Name (if any/ Floor
Street Address L/ _-�> P- Apt. Na.
City `' f,/ S✓ ��� tips -%Zoz
Deleading Nathodt DR! SCRAP BEAT CUM ENCAPSULATION D6NOLITION
(circle all that apply
POOR S&RZI C CAUSTICS r 'REPLACEMENT------, Orm
Ir •Other• selected, please explain
Check cast
p� JJdwelling is Multi -roily single roily
Start date% `/ Coaplstion Date —
When will work Be donei an �p--- weekends?
Project Supervisor Hama,
Property'Owner sq(y
Certificate I 'OS CLOD 9lj 3
Addresa4 (/vc�$ P
City �l�i�✓� f/ !��(yy�� Stato_! j Zip 0 C)t
relepAone
In case of eaergancy contacts
Phone: dsy,-�'c2g�', 2ZZ--4 /LDS- evening
(OVER)
00148/5 rev 116189
In accordance with Chapter 773 of the Acts of 1997, Massachusetts GeneralLaws
C. 111 §197, 454 CMR 22.00 and 105 CMR 460.000, notice of the date and method(s) of
removal or covering of paint, plaster soil or other accessible material containing
dangerous levels of lead, is to be provided to the following persons at least five
days prior -to -the begiruidnp o2tide_lwdiny,
1. Occupants of the dwelling unit
2. All other occupants of the residential premises, if any
J. Director, Chlldhood'Load poisoning'preventian Program
Depart"At of Public dealth, 305 South Street, Jamaica Plain, MA 02130
4. Lead Removal Program, Bureau of Technical Services
Department of Labor and Industries, Division of Industrial Safety
100 Caoerldge.Street, Roan J101, Boston, MA 02202
5. 1"'&" BOi&d'" Se01W<oile CDforceswnt Agaacv
6. Massachusetts Qistorical Cosaission
(it prealses Is listed an tha State Register of 6lstoric Placed
The undersigned herebv states, under the penalties of perjury, that ha/she has read
and understood the Car•oawealth of Massachusetts Deleading )tegulations, 454 CMR
22.00, and Load poisoning Prevention and Control Regulations, l05 CM 460.00, and
that the inforastion contained in this notification is true and correct to bast
of his1sheer know! /ge and belief.
Date Signed
Title: ✓�,
Coapanv: /V6</� Cv,-2/-c
- ------- -- - - --
Office
OZ3411/6 rev 116199