HomeMy WebLinkAboutSouth Main St. #465 - 12/13/2007Dec 01 2007 5:31PM HP LRSERJET FRX
WAIVER #HV-05360
COMMONWEALTH 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. Ch. 111, § 197,
454 CMR 22.00 and 105 CMR 460.000 as most recently amended
File Number: (AGENCY USE)
Contractor performing project Mark S. Bianco License # DC 001055
Lead Paint Inspector Scott Bascom License # I-3244
Date of Inspection 7/28/02
If low -risk deleading work is being performed, complete the following line:
Property Owner: N/A Agent:
Address of Project
Building Name (if
Floor I
Street Address 465 So. Main St. Apt. No.
City Mansfield Zip 02048
Deleading Meth Wet/Dry Scra
Liquid Encapsulant Covering
If "Other" selected, please
Check One: Dwelling is multi -family
Start date 12/11/07
Heat Gun Caustics
Demolition ep aceme t Other
Single family X
Completion date 12/13/07
When will work be done: A.M. X P.M.
Weekends X
Project Supervisor's name Mark Bianco License # DC001055
Property Owner Andrew Tillman
Address 465 So. Main St.
City Mansfield State MA Zip 02048
Telephone_ (508)337-6222
In case of emergency contact Mark Bianco
Phone: day (617)340-0816 evening f781 340-0544
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In accordance with Massachusetts General Laws C. III §197, 4$4 CMR 22.00 and 105 CMR 460.000, notce of the date and method(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 agencies, at least 37A ( 10 ) days prior to the beginning of deleading.
NOTIFICATIONS MAY BE FAXEA.
I. Department of Labor, Lead Program, Division of Occupational Safety
399 Washington Street, 5" Floor, Boston, MA 02108
FAX; 617-727-7568
2. Director, Childhood Lead Poisoning Preven Hon Program
Department of Public Health, Donovan Health Building, 5 Randolph Street, Canton, MA 02021 FAX: 781-774-6700
3. Occupants of dwelling unit
4. All other occupants of the residential premises, if any
5. Local Board of Health/Code Enforcement Agency
6. Massachusetts Historical Commission (if premises are listed on the State Register of Historic
220 Morrissey Blvd. Places, this notification must be made upon receipt of an
Boston, MA 02202 Order to Correct Violations or at least 30 days prior to
FAX (6M 727-5128 Initiating
preventive deleading)
NOTIFICATIONS SHALL BE COMPLETED IN THEIR ENTIRETY, DATED AND SIGNED - INCOMPLETE NOTIFICATIONS WILL NOT
BE ACCEPTED AND WILL BE RETURNED BY THE DEPARTMENT OF LABOR & WORKFORCE DEVELOPMENT,
PROPERTY OWNER ( If owner or unlicensed owner's agent will be performing low -risk deleading work, complete the following):
Property Owner _
'telephone
1 certify that 1 have complied with the training requirements of the Commonwealth of Massachusetts Lead Poisoning Prevention and Control Regulations, 105
CMR 460.175, for owner/agent low -risk abatement 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 Ilquid eneapsulant capping baseboards
removing doors, cabinet doors, shutters
Applying exterior vinyl siding covering surfaces
i certify that all the information contained in this notification is true and correct to the best ore best ofm�and belief.
Date
"" Signed
1
Revised 04/2007
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CLEAN SURFACE DELEADINGO, INC.
203 Essex St. (781)340-0816
Weymouth, MA 02188
FACSIMILE COVER SHEET
DATE: November 30, 2007
TO: Director, Asbestos & Lead Program
(617)626-6965
Director, Childhood Lead Poisoning Prevention Program
(781)774-6700
Board of Health, Town of Mansfield
(508)261-7343
FROM: Mark S. Bianco
RE: Notification of Deleading Work
465 So. Main St., Mansfield, MA
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