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HomeMy WebLinkAboutFisher Ln. #25 - 9/30/2005Mar-06-05 17:05 matt griffin 5083373098 P.Ol f)cpartrncol of Public I lealth - childhood Le' Poisoning Prevention Program Deleading Notification Please complete all sections of this fnrtu clearly. Tncomplcte or illegible forms will be retu'05 MAR rned. 7 HM13:0nl Lead Paint InspectorPy\-t,-k-e , '�_o FTi � grLs .- License # 1.-755.1 Inspection Date AW-4-- Property Owner �l�4}1,ew,rirFF1 -N .. Zi Property Owncr's Address_'> Ij t � : 1 .— -- — — — P Code s G L_ ..— Authorized person performing work: i lfi w �>i-reF,.�. LiclUAuth.UG, p• p g hlL_ls— — Zip Code�y 4u — Address of authorized person r c r rl'N — -- -- — — Telephone Number <) +) -'.?'N Address where the work will be done: floor... — Building Name (if any) —.._ —. -- _ Apt No._ Street Address_3� sh r,! ,4N — —Lip Code,_ 'fhc property is a_ ,_multi-ftunilY .�z single family. Dcleud'n Methods : a Making paint intact (high risk) pf Making paint intact (moderate u Applying vhry) siding on exterior ❑ Demolition risk) of Component removal (low risk ❑ Scraping ❑ Liquid ericapsulant components) !4 Component removal/replacement jot Covering ❑ Other;-- .-- T — ❑ Dipping ❑ Capping baseboards The work will begin ern/alU turd will Finish by?i. The work be done in the ✓ am vent or J weekends. In Case of Emergency Concoct 'N) w EF . Daytime Phane� rS_' }7 ) ' �� _. _ Evening Phone.— '1.'he Property Owner must complete anti sign the following information: I certify that only authorized persons who have complied with the training requirements of the Massachusetts Lead Poisoning Prevention and Control Regulations, 105 CMR 460,000, will conduct deleading work. 1 further ccrtity that the aulhorized person(s) will not exceed the scope of his/her authority and will be performing only those activities indicated above. All of the information t:ontaincd in this document is true and correct to the best of illy knowledge and belief. Date ti G Signed. �: 1 —,- Tile following people/agencies must be notified ten days before beginning work: I , Occupants of the dwelling unit 2. All other occupants of the residential premises, if any work will be done in the common areas 3. Childhood Lead Poisoning Prevention Program, DPTI Fax (181) 774-6700 MWRIIO 5 Randolph St, Donovan Building Canton, MA 02021 4. Asbestos and Vead Prukrarn, DLWD 399 Washington St.. H(.iston, MA 02108 Fax (617) 727-7568 5. Local Board of Health/Code Enforcement Agency • If the home is on the State Register of Historic rlaces. ctdl nm MA I lislorical Commission at (617) 727-8470.