55 Deleading Work Form 2015 OP/11/2015 TUE 10:46 FAX
+++ Northampton Board Health
Notification of Deleading Work
2991/0/12
Page I of 1
Department of Labor Standards
19 Staniford Street, 2nd floor
Boston, MA 02114
www.mass.gnvfdols
Department of Public Health
Childhood Lead Poisoning Prevention Program
Donovan Health Building
5 Randolph Street
Canton, MA 02021
www.mass.q ov/dph/clppp
NOTIFICATION OF DELEADING WORK
AN saC rrs of this form must be completed In order to comply with the noflfkarbn requirements of
M.G.L.C. Ills 197,454 CMR 22.00 and 105 CMR 460.000,as most recently amended.
This Notification Is[Routine Notification N.0-1 submitted at feast 10 days prior to project start date
NOTIFICATIONS MOST BE SIGNED,DATED AND COMPLETED IN THEIR ENTIRETY.INCOMPLETE NOTIFICATIONS WILL NOT
BE ACCEPTED.
Project Information :A proper address is critical All addresses must be verified through the LISPS
database Address Verification
House Number:
Street Type
City:
(Ave
vj
Property Owner/Agent. !EH*Coast Managt
Owner Address:
TYPE OF DWELLING:
Street Name:jgnq
Unit/Apt iS2 I
Number
Zip Code 101060 I
Phone:
Email:
Second Property J
Owner/Agent: Phone 2.
Owner Address 2 Email
address 2:
TYPE OF DWELLING 2: f-Select- v
Inspection Information: Before starting any work,contractors should check a property's previous lead
inspection history at CLPPP Lead Inspected Homes Qatabase
1413-256-3442
hnariaaabileinc.cc1
Name of Licensed Lead
Inspector/Risk: •
Inspectorr/Risk Assessor
License Number:
Date of
Inspection:
Joseph Cauado
3147
03!22/2015
Date of 103/22/2010
Expiration:
DELEADING CONTRACTORS AND MODERATE RISK SUPERVISORS PERFORMING DELEADING WORK:
PROPERTY OWNERS AND/OR OWNERS AGENTS PERFOMING LOW OR MODERATE RI
WORK ON THEIR OWN PROPERTY: =
httpl/ewcdet ma.orglde leadingwodmotification.aspx 8/11/2015
uG/LVluLe 'TUC Lu:et PAX eee o tnamptOn Beare Health ti0002/002
'j DELEADING CONTRACTOR
Page 1 oft
DELEADING NOTIFICATION FORM
DELEADING CONTRACTOR
OLS-NOOERAUE RISK sUPERNS WLEAo-WE RENOVATION CONTRACTOR
*THIS SECTION MUST BE COMPLETED BY THE()BLENDING CONTRACTOR OR THE MODERATE RISK
SUPERVISOR/LEAD-SAFE RENOVATION CONTRACTOR WHO WILL BE PERFORMING THE DELEADING WORK.
CONTRACTOR INFORMATION
Contractor Name: [Abide Inc
Contractor PO Box 886,483 Shaker Road
Address:
City: East Longmeadow 41 Stag:I AAA vj Zip Code:101028
Contractor Contact !Jerry Gray J
Person:
Office Phone: 4i 3-5250644 I
Contractor License Number:i DC vi1001b1B I
Cell Phone:
Expiration Date
TYPE OF DELEADING WORK TO BE PERFORMED
Clan I Dela:taw Methods(check a)I that*pep__
Email:imana @abdehlc.wnl
I06/252015j
ID N/A
❑Abraavc feasting with wemsfng tecnnI R or emulaecos vacuuming system(EMERIOR n5E ONLY)
o Ca sticsla of mahyane chloride 6 proM13iRtl)
Moderate Rik Dd:ading McMada(ekeek all that apply)
DNA
O Capng Baseboards
ri Coven
R tarn.
Love Risk&leading MShods(check a8 that aP@ly)
El N/A
❑Ca nno Baseboards
❑Cowering
( v
WORK SCHEDULE
Project Start Date: /OW2 2015 IN
V
Project Completion Date:i`O/042016 �®
List the hours the work will be conducted: Start time:17:00AM vJ End Time:[500 PM vi
In accordance with Massachusetts General Laws C. 111, sec. 197, 454 CMR 22.00 and 105 CMR 460.000, notice
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 10 days prior to the beginning of the deleading work.By submitting
this form electronically,
notification will be jointly provided to:
http://ewr.detmaorg/DeleadingContractor.aspx
8/)12015