HomeMy WebLinkAboutSouth Main St. #125 - 1/4/1996DEPARTHENT OF PUBLIC HKALTH/DEPARTHENT OF LABOR & INDUSTRIES
NOTIFICATION OF DELRA ING WORK
All sections of this fors: must be completed in order to comply
with the notification requirements of K.G.L. C. 11 197
File No.
Project Contractor DELEADERS OF NA, %NC. Certif. No.
Lead Paint Inspect or�7tb} Date of Inspect. LI.LI /9s`
Address of Project:
Building Name Floor
Street 1 5 5eyii•1.Mf-t4•57i Apt.
_.
City tJAWS�/6[r-> MA Zip ®2o'f
Deleading Method: Vr Scrapin Heat Gun Encapsulation Demolition
(Circle All) ower Sanding Caustics Replacement Other
If "other" selected, explain -• ---•....-
Check One: dwe li g is multi -family Single family r
Start Date < • 1 2 qC, Completion Date : 41tt lq -
When will work be done: am ✓ pm weekends
Project Supervisor's Name �7�BA 33 .•. Certif. No. b 2136
Property Owner PPrul Sfl3TocJ SK \ Phone # (5s8J 3 QihS4
Street -•+ 1Z5 5;.M," 5T ................... .......
City ..... . NA�Si'f6Lb , MA Zip 0Z-0447.
In case of emergency contact: DSLEADRRS OF MA, INC.
Phone: day (617) 878-9591 evening (617) 878-9591
In accordance with Chapter 773 of the Acts of 1987, MA Gen. Laws C. 111 197, 454
CMR 22.00 and 105 CMR 460.000, notice of the date and metbod(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 5
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 Dept. of
Public Health, 305 South St., Jamaica Plain, MA 02130.
4. Lead Removal Program, Bureau of Tech. Services, Dept. of Labor
and Industries, Div. of Industrial Safety, 100 Cambridge St.,
Room 1101, Boston, MA 02202.
5. Local Board of Health/Code Enforcement Agency.
6. MA Historical Commission (if premises is listed on the State
Register of Historic places).
The undersigned hereby states, under the penalties of perjury, that he/she
has read and understood the Commonwealth of MA Deleading Regulations, 454 CMR
22.00,and Lead Poisoning Prevention and Control Regulations,105 MR 460.000,
and that the information contained in this notification is true and correct to
the best of his/her knowledge and belief. �(
Date 12 /%5 /9-cS Signedk0trA;RRS
� 1x`��. ....... . . . . .
Title ctor #DC00 4
Company OF MA, IN
- - - - - - - - - - - - - = - - - - - - - - - - - - - - -. - - - - - -
Office Use Only
0034B/6
form2.dom
rev 1/6/89