HomeMy WebLinkAboutWest St. #39 - 10/28/1994DEPARTMENT OF PUBLIC MEALTM/DEPARTMENT OF LABOR i INDUSTRIES
NOTIFICATION OF DELS"D C MIRK.
All'sertioas of this form must be completad In order to ooeply with
the notification repulrernts of M.C.L. C. 111 §197
,ry
/ FILE NUMBER
Contractor parroxulag project %2 Sep LC7/J1 9(l Certification I O�C-CJoc�-7G/
Lead Paiat lbspector/`7/ Lea P,92L;; i c/vcS Date of inapectioo
Address of Prolece
Building Naaw (if any) Floor
Street Address, —
Deleadiag Methods
(circle all that apply)
Apt. No.
lCR.IPIM? JMAT GUM ENCAPSULATION DEMOLITION
POKER SANDING CAUSTICS REPLACEMENT OTHER
If •Other• selected, please explain
Check one: dwll g is Multi -tautly Slagle family
start date /c- -27y Com/pletion Date
When will�vork to doses an / P�y roekends7 q/,
Project Superoiso-r Name"�,/%2� GO✓��( Certificate
Property owner/y/'2W/P,
cit W`L? /S�iP�G�'�StateASS _ zip 06 o
Telephone 3-39'- (% c�0��G�
In case of emergency contact:
Phone: day �1//y ,g— evening
(OVER)
00348/5 rev 116189
In accordance with Chapter 771 of the Acts of 1997, Massachusetts Ceneral�¢ava
C. Ill 9197, 454 CMR 11.00 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-"a "Onninp-01440 oading.
I. Occupants of the dwelling unit
1.' All 'Other 'occupaots of the residential premises, if any
�.. Director;` Ch12000d'Lead poisoning prevention Program
Drparesent of Publio dealth, 305 South Street, Jamaica Plain, MA 07110
4. Lead Ramovel Program, Bureau of rachnical Services
Department of Labor and Industries, Division of Industrial Safety
100 Goo;;ldge.Seraet, Rooms jl01, Boston, MA 07702
S. .i�ca�t �s!!!d Of llaelLhlC»ra"o J:ulcs;se:.ane Ay+iucy
6. Massachusetts Qistorical Coaaisslon
(if psemis08 is listed on the jut* Register of Sistoric Placasj
The undersigned hereby states, under the penalties of perjury, that he/she has read
and understood the Coreomvealth or Massachusetts Deleading Regulations, 454 CXR
72.00, and Lead Poisoning prevention and Control Regulations, 105 CAR 460.00, and
that the information cWtalned in this notification is true and corracc to the best
of his1her Anovledge and belief.
DeteAZ9
Signed: G
ritle:� �—
Cospanyr 91
—�;_59✓z�
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Office C;e Only - - - - - -
0S34B/6 rev 116199