HomeMy WebLinkAboutCentral St. #103 apt.1 -1/15/1997COMMONWEALTH OF MASSACHUSETTS
Department of Labor & Industries and Department of Public Health
NOTIFICATION OF DELEADING WORK
All sections of this form must be completed in order to comply
with the notification requirements of M. G. L. c.111 & 197,
454 CMR 22.00 and 105 CMR 460.000 as most recently amended
FILE NUMBER: (AGENCY USE)
Contractor performing project Manuel S Dasilva License # DC000217
Exp.date 01/18/97
Lead Paint Inspector John Eastman License# M1184/R1184
Date of Inspection 11/27/96
If low -risk deleading work is being performed, complete the following line:
Property owner Agent
Address of Project
Building Name (if
Floor
Street Address 103 Central St Apt. NO. 1
City
Deleading Method:
Liquid Encapsulant
Wet/Dry Scraping
Coverin
Zip
119M
Heat Gun Caustics
Demolition Replacement Other
If "Other" selected, please explain Stripping 2 doors
Check One: dwelling is multi -family Yes single fami
Start date 01/13/97
Completion date 01/15/97
when will work be done: A.M. 8 P.M. 4 Weekends?
Project Supervisor's name Antonio Cardoso License # DS000839
Property Owner
City Attleboro State MA
Telephone
In case of emergency contact Maria E Dasilva
Phone: day (508) 583-8485 evening Same
(over)
Zip 02703
In accordance with Massachusetts General Law c. 111 § 197 CMR 22.00 and 105 CMR 460.000
notice of the date and methods (s) of removal or covering of paint, plaster or other accessible materials
containing dangerous levels of lead is to be provided and must be received by the following persons, at
least ten 10 days prior to beginning of deleading.
1. Occupants of the dwelling unit
2. All other occupants of the residential premises, if any
3. Director, Childhood Leading Poisoning Prevention Program Fax (617) 753-8436
Department of Public Health, 470 Atlantic Ave., Boston, MA 02110
4. Director, Asbestos & Lead Program Fax (617) 727-7568
Department of Labor & Industries
Room 11006, 100 Cambridge Street
Boston, MA 02202
5. Local Board of Health/Code Enforcement Agency
6. Massachusetts Historical Commission
220 Morrissey Blvd.
Boston, MA 02125
Deleading Contractor
(If premises is listed on the State Register
of Historic Places, this notification must be
made upon receipt of an Order to Correct
violations or at least 30 days prior to
initiating preventive deleading
Fax (617) 727-5128
The undersigned hereby states, under the pains and penalties of perjury, that he/she has read and
understood the Commonwealth of Massachusetts Deleading Regulations, 454 CMR 22.00 and
Leading Poisoning Prevention and Control Regulations, 105 CMR 460.000, and that the informa-
tion contained in this notification is true and correct to,#pjbest of his/her knowledge and belief.
Date o] im197 Sig
Title ' tdeleader
Company Dasilva Deleading Contractor
Property Owner (If owner or unlicensed owner's agent will be performing low -risk deleading work)
I certify that I have complied with the training requirements of the Commonwealth of Massachusetts
Lead Poising Prevention and Control Regulations, 105 CMR 460.175, for owner/agent low -risk abate-
ment and containment. I further certify that I or my agent will be performing the following low -risk
activities (I have circled all that apply) :
applying liquid encapsulant caRpiog baseboards
applying exterior vinyl siding covering outfaces
removing doors, cabinet doors, shutters
I certify that all the information contained in this notification is true and correct to the best of
my knowledge and belief.
Date: Signed*