HomeMy WebLinkAboutCentral St. #119 - 6/18/??The Commonwealth of Massachusetts
Executive Office of Labor NOTIFICATION OF
Department of Labor and Industries ASBESTOS WORK
PETER G. TORKILDSEN, Commissioner
Lcverett Saltonsta0 Building
100 Cambridge Street, Room 1101 (In accordance with the provi;Iona of 0 t
Boston, MA 02202.0003 M.G.L. c.149, ss.6.6F and 453 CMR 6.12)
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Do,prevailing rates of wages apply to tthiis project ss 'rcqu'ved under'M.C.I.. `o. f49, ie. 76,-27 or 27F7 (cuele orjo
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».1. Building Nama (if any)..; .. j/J , %L ^ tOF..• nr , ��' +.' �> i,
Street Address
Orty .4N.SF%JAG D Stara p `
2. Project type (circle one): DEMOLITION
If "OTHER" selected, please explain
RENOVATION r ,. .,,„ OTHER `
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3. Asbestos Activity (circle one): ENCAPSULATION' ASSOCIATED PROJECT ENCLOSURE REMC
Indicate amount of:. asbestos surface on pipes or ducts —0 LINEAR FEET or asbestos surfa
structures other than pipes or ducts to be remover, enclosed or encapsulated SQUARE?
4 StartDato ='a �' 1'� ` workhours weekends?_(cireloone)
Completion Date—�
5 Project Su eryisorName EN) 7IniNe�� CertificateX
Asbestos Analytical Lab Name �I �/LN19 G l 7-76Certificate p
Project Monitor Name I (UN �LJTY-I Certificate# tt'
BBa
6.. Name & Address of disposal sites)
7. Is asbestos contract written or verbal?
8. Contractor's Workers' Compensation Insurer
Policy Numbcr' . . Expiration Date
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` 11
YF ,
M"Yc`^'t
y. Facility Owncr
Address
City Stale Zip
10. Description of work practices to be followed:
1-1j3 &w2- La l/ �..)
it. Description of decontamination system(s) to be used CiN E' 11 AM C'�i ?tS
12. Description of handling/disposal methods to comply with 453 6.14(2) (g)
6�ie% I`.�c.ti✓N /�-fht�,.c() 1Ln��r� r,�.r�: G -.,,c_ �.`1� ;?—
13. Name and address of transporter(s) if other than the asbestos contractor:
The undersigned hereby states, under the penalties of perjury, that he/she has read and understood the
Commonwealth of Massachusetts Regulations for the Removal, Containment or Encapsulation of Asbestos, 453
CMR 6.00, and that the information contained in this notificalion is true and correct to the best of his/her
knowledge and belief,
Dale
please return this form to:
Rev. II/91
Signed: - " L
Company:
Address: I iG"�✓?.V % )
Phone:
Department of Labor and Industries
Bureau of Technical Services
Leverett Saltonstall Building
100 Cambridge Street, Room 1101
Boston, MA 02202-0003