HomeMy WebLinkAboutSamoset Ave. #40 apt.1 - 9/28/1993DEPARTMENT OF PUBLIC HEALTH/DEPARTMENT OF LABOR Q INDUSTRIES
NOTIFICATION OF DELEADING WORK
All sections of this fora must be completed in order to comply with
the notification requirements of M.G.L. C. 111 1197
FILE NUMBER
Lead Paint InspectorSLOWl- - 1-1F(Ute of Inspection 24 3
&;ntractor performing project k) License �_j�,L,00`F�23
Address of Project
Building Name (if any) Floor 1 5 j
Street Address '10 5A MSLS9T " PWl — Apt. No.—
CityVVV)tJSF:(f_L-b zip__' 021
Deleading Method: <IM-Y_SCRAPIHC "SEAT GUN ENCAPSULATION DEMOLITION
(circle all that apply) ./
POWER SANDING CAUSTIC REPLACEMENT OTHER
If 'Other" selected, please explain cEhT. SCR, i!)Nrr
Check one: dwelling is Multi -family
Start date
single family
Completion 'Date 9 I I �l3
T
When will work be done: am "n OCb pm LOD weekends? AJ a
Project Supervisor Name R aB e.ez-_C 1'LtRR{ R 0-r__ License # n, S, 60z `T 6
Property Owner G-R4Z `� G_R1%_E (Q
Address q0 SA-M6gamV tq-V�_
city MytWsy f-L'�o State YAW zip ozc)L6
Telephone l (Sy F) 3 32 5-021
In case of emergency, contact what person:
Phone: Area code required day(b eveningL41%) 32 E -OS-Qq
(OVER)
0034B/3 rev 12/05/90
In accordance with Chapter 773 of the Acts of 1987, Massachusetts General Laws
C. 111 5197, 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 beginning of deleading.
1.` occupants of the dwelling unit
2. All other occupants of the residential premises, if any
3. Director, Childhood Lead Poisoning Prevention, Program
Department of Public Realth, 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 Cambridge Street, Room 1101, Boston, MA 02202
5, t;�.._ti a.,..�,.it �taattb/Ccde:�nforc+yaeat ARen99.
6. Massachusetts Historical Commission
(if premises is listed on the State Register of Historic Places)
The undersigned hereby states, under the penalties of perjury, that s/he has read
and understood the Commonwealth of Massachusetts Deleading Regulations, 454 CMR
22.00, and Lead Poisoning Prevention and Control Regulations, 105 CMR 460.00, and
that the information contained in this notification is true and correct to the best
of his/her knowledge and belief.
Date Signed:
Title:
Company:
Address:
Telephone #:
Office Use Only
rev 12/05/90
0034 B/6
In accordance with Chapter 773 of the Acts of 1987, Massachusetts General Laws
C. 111 5197, 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 beginning of deleading. _
2.occupants of the dwelling unit
2. All other occupants of the residential premises, if any
3. *Dtrector, Childhood Lead Poisoning Prevention Program
�• Department of Public Health, 305 South Street, Jamaica Plain, MA 02130
4. Lead Removal Program, Bureau of ?achnical'Services •••
Department of Labor and Industries, Division of Industrial Safety
100 Cambridge Street, Room 1201, Boston, XA 02202
5. Local board of tiedlin/Code Z-bUotc6WW t .'.,bins•:,
6. Massachusetts Historical Commission
(if premises is listed on the state Register of Historic Places)
The undersigned hereby states, under the penalties of perjury, that s/he has read
and understood the Commonvealth of Massachusetts Deleading Regulations, 454 CM8
22.00. and Lead Poisoning Prevention and Control Regulations, 105 CMR 460.00, and
that the information contained in this notification i true and correc to the best
of his/her )mow'edge and belief.
Date
2 3 Sigaed:
Title: C --v u
Company:2b/lTA-' W515Atj 'i-JU .S�-/(v .
Address: Z L 12y-NI&JF W, r26 Ur��
Telephone h 6 1 7 3 Z S- -USI
A
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Office Use Only
rev 12/05/90
0034B/6