HomeMy WebLinkAboutLinden St. #25 apts. 2&3 - 4/10/1994DSPARr13NT or PUBLIC NEALTN/DEPAnxsnT or LABOR i rNDusmss
NMXFiCATION Or Dd "Zt C WORK
All sections of this form must be completed in order to comply with
the notification requirements of Y.C.L. C. 111 9197
FILE NUNBER
contractor performing Projec
t �A2R C,11by(l,,14 Ccl Certification /)C
Lead Paint Inspector �1 LE �/� l ,�%j Date of Inspection
Address of Project
Building Name (if any) Floor
Street Address Line S� Apt. No. '
City / / /F%NS/ iP� tip CL;� OL/�
Daleading Methods Mr SCRAPING EEAT OUN ENCAPSULATION DrM=rTrom
(circle all that apply) —�
PONER SANDINC CAUSTICS �RSPLACENEHTm OTEu
If mother' selected, please erplaln
Cheek ones dwelll'ing its Multi -family single family /
Start date d f Compllotioo Date /AL%/'�
when wilhwurh be donor as '�
Project Supervisor Name Certificate
Property Owner c��e��_ -�
Address / J (_C>varv� L/,C- x
City_C7 �� State i�%%%� Zip v/ lw
Telephone !n%
In case of emergency contact: �Fl�c C ��/✓ J
Phone: day ���. _ �l� S� evening
(OVER)
0034DIS rev 116189
In accordance with Chapter 771 of the Acts of 1987, Massachusetts General Laws
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 CO the following persons at least five
days prior -to -the DeyLuitny otpe=ending.
!. Occupants of the dwelling unit
2. All other occupants of the residential premises, If' any
J. Director, Childhood'Lead Poisoning Prevention program
Department of Public Health, 305 South Street, Jamaica Plain, MA 02130
4. Lead Ramoval program, Bureau of ?echnical Services
Department of Labor and Industries, Division of Industrial Safety
100 Cambrid9e.Sereet, Rooge 1101, Boston, MA 02202
5. Local board of Health/Code Entorcaftnt Agency
6. Massachusetts Historical Cox-atasion
elf premises is listed on the hate Register of 8lstorlc Places)
The undersigned hereby states, under the penalties of perjury, that he/she has read
and understood the Commoowealth of Massachusetts Deleading Regulations, 454 CMR
22.00, and Lead poisoning Prevention and Control Regulations, 105 CMR 460.00, and
that the information in this notiticatlon is d,correct to Dtst
of his/her wledgand belief.
and Dellet. �
bat• 7 Signed:
?Stle:-7----
COMpan'J'
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Office Use Only
0:J4B/6
rev 116199