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41/43 Deleading Paperwork H. fo c. • '.. 1. 1 1! � :r _ - I . c • • s• • ° � s; • i '� e • EE rv ' ' ., a . • • 4/18/2014 FRI 10: 07 FAX ■ Northampton Boara neap Page 1 of 1 TILE COMMONWEALTH OF MASSACHUSETTS Department of Labor Standards Homepage: www.mass.gov/dols Thank you for your submission. Your confirmation number is: 1870900. A confirmation email has been sent to:jerry@abideinc.com. http:7cwcdetma_org/Confirmation.aspx 4/18/2014 Department of Public Health-Childhood Lead Poisoning Prevention Program Deleading Notification lease complete all sections of this form clearly.Incomplete or illegible forms will be returned. tN\ !N .� i ^S License# (t'))21 N 3 / Inspection Date 7 Z o o end Paint Inspector \6 —. Litt d1 moony Owner rtM VIrist) Lin yl 1C Zip Code G t 0 ropeny Owner's Address 2-t 1-2---4 d T�f-t`� I cl f i�t`2- \\ ,, t�l Ly,\)r �1 e.r-f= Lic#/Ruth.# 1 9 5 ` L - 6 M tuthess of person performing work: z - A,aJ;(lE M l Zip Code 4 rddress of authorized person L t 6=Y1 v r '�°_(el- t�'� • ��`� elephone Number(413 ` 7 Lp o - 7 c a address where the work will be done: Building Name citeex Zip a u ,ity D� .P i Zip Code lt2C#4 m The property )eleadina Method(s): Making paint intact(high risk) Demolition ;craning omponent removalreplacemeni Dipping Floor ! /apt No. I a'. multi-family_single family. ❑ Making paint intact(moderate risk) ❑ Liquid encapsulant v'Coveting ❑ Capping baseboards ❑ Applying vinyl siding on exterior eV-Component removal(low risk components) ❑ Other. the work will begin on0.Z and will finish by /5a/1 L 11te work will be done in the_am im or weekends. In Case of Emergency Contact kae'er' L. Vua+p--n _ Daytime Phone C3 7— Y 7 $ qi Evening Phone 7 fo `-d Property Owner most complete and sign the following information: rtify that only authorized persons who have complied with the training requirements of the Massachusetts Lead Poisoning tendon and Control Regulations, 105 CMR 460.000,will conduct deleading work I further certify that the authorized lon(s)will not exceed the scope of his/her authority and will be performing only those activities indicated above.All of the emotion contained in this document is true and correct to the best of knowledge and belief. _ Date 1 G I y/1 Signed The following people/agencies must be notified ten days before beginning work: * Occupants of the dwelling unit 0,--C_01 `)- All other occupants of the residential premises,if any work will be done in the common areas Childhood Lead Poisoning Prevention Program,DPH Fax(781)774-6700 MWRHO 5 Randolph Street,Canton,MA 02021 Asbestos and Lead Program,DLS 19 Stanford St, 1'Floor,Boston,MA 02114 GtC_Act'\A— Fax(617)626-6965 Local Board of Health/Code Enforcement Agency If the home is on the State Register of Historic Places,call the MA Historical Commission 4(617)727-8470. !2016 PRI 10: 01 FAX ' Northampton nUO.0 Notification of Deleading Work Page 2 of 2 DELEADING CONTRACTORS AND MODERATE RISK SUPERVISORS PERFORMING DELEADING WORK:i-. a0' rpyA sco n. -1 PROPERTY OWNERS AND/OR OWNER'S AGENTS PERFOMING LOW OR MODERATE RISK DELEADING WORK ON THEIR OWN PROPERTY: tt .e ICA nta•eu. 1. 4/18,/2014 h arrifeWr.derma.org ldeleadingwodmotification.aspx /2014 FRI 10 01 FAX "' Northampton :wow: DELEADING CON I RACTOR Page 1 of 2 DELEADING NOTIFICATION FORM DELEADING CONTRACTOR ohs-MODERATE RISK SUPERVSOR/LEAD-5ArL RI NOVA noN CONTRACTOR *THIS SECTION MUST BE COMPLETED BY THE DELEADING CONTRACTOR OR THE MODERATE RISK SUPERVISOR/LEAD-SAFE RENOVATION CONTRACTOR WHO WILL BE PERFORMING THE DELEADING WORK. CONTRACTOR INFORMAL ION: Contractor Name: Abide,Inc. Contractor P GBox 886;483 Shaker Road'. Address: Coy: East Longmeadow State: MA Lip Cock 01028 Contractor Contact Jerry Gray Person: __. Cell Phone: .413 25011024 Email: Office Phone 413525-0644 . jE'ry @abidEnn coo Contractor Ucense Number: DC 001619 Expiration Date: 08)25/2014 Efil TYPE OF DELEADING WORK TO BE PERFORMED: Class 1 Dckadmg Mcthad5(checL all that apply) Li WA AGasxe Blasting with wet misting techniqueei 4mnllaneou4 vemuming system(Screi1OR USE ONLY) i Caustics(use a`metly:ere mlonde is vomited) +._Covering )tolerate Risk Deleading Metheds(cdieck all that apply) WA ':capping ea[Waards :'1ICOVenng ".T_timid H1apsuixngn I.ow Risk Deleading Merhods(chcck all that apply) C_:Capping Baseboards iCtcwering Lguid Encaps'Jlalian WORK SCI4F.DCt1t _— Project Start Date' 0510112014 IJ Project Completion Date 05)06'2014 List the hours the work will be conducted: Start time End Time 5pm lam In accordance with Massachusetts General Laws C. iii,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 at least 10 days prior to the beginning of the deleading work. By submitting received by the following agencies, this form electronically, notification will be jointly provided La: 1) Department of Labor Standards, Lead Program, and 2) Director,Childhood Lead Poisoning Prevention Program(CLPPP), Department of Public Health Notification Is also required to be provided to the following: 4/18/2014 http:L)eva.derma.org/fkleadingeortracior.aspx /2014 ?RI 10: 01 PAX Nortbartp=On Board Hearn, DELEADLNG CONTRACTOR Page 2 of 2 3) Occupants of the dwelling unit if any All other occupants of the residential premises, y 5) Local Board of Health/Code Enforcement Agency Notifications should be submitted eelecddresses:thBru email to Health E of l health. s_ards Click the link to see a listing email a 6) Massachusetts Historical Commission, 220 Morrissey Boulevard, Boston,MA 02202 If premises is listed on the State Register if Historic Places, this notification must Fax(617) /27-5128 be bein made upon receipt of an Order to Correct Violations or at least 30 days prior to initiating g By submitting this form,the undersigned hereby states,under the pains and penalties of perjury, understood the Commonwealth of Massachusetts Deleading and lead-Safe Renovation regulation, that he/she has read and 454 CMR 22.00,and the 105 CMR 960.000, and that the information in Lead Poisoning Prevention and Control regulation, this notification is true and correct to the best of his/her knowledge and belief. Name: Maria Tllli '. Date: 04/1812014-' $tLDmi[i:J 4'18/20)4 http:I iewr.detma.org/DeleadingConiractor.aspx 9;2014 FRI 10: 00 FAX --r NOrthamptOn Boar( neo Notification of Deleading Work Department of Labor Standards 19 Staniford Street, 2nd Floor Boston, MA 02114 Dov/dots Page 1 of 2 ■ Department of Public Health Childhood Lead Poisoning Prevention Program Donovan Health Building 5 Randolph Street Canton, MA 02021 www.masscioA/doh/cIpop NOTIFICATION OF DELEADING WORK NI sections . this roan must CMR 2 completed 0 nd 105 CM 460.000 with as notification requirements of M.G.LGIII s19l, This Notification Routine Notification submitted at least 10 days prior to project start date is NOTIFICATIONS MUST BE SIGNED, DATED AND COMPLETED IN THEIR ENTIRETY.INCOMPLETE NOTIFICATIONS WILL NOT BE ACCEPTED. Project Information : A proper address is critical. All addresses must he verified through the liSPS database Address Verification House Number: Street Type City: Property Owner/Agent: Owner Address: Second Property Owner/Agent: Owner Address 2 TYPE OF DWELLING: 54 St Northampton Sue Krause 15 Jutland Road, Bin. Hampshire Property f, 25 New South Street, Multi-Family Hom<f,,`:, Street Finn Name: Unit/Apt Number: Zip Code:01060 Phone: Email: 413-695-2228 .unknown @unk Please enter a valid email address Phone 2: ''.413.695-2228- Email address 2: Inspection Information: Before starting any work,contractors should check a property s previous lead inspection history at CLPPP Lead Inspected Homes Database Name of Eileen Manle! Licensed Lead - Inspector/Risk: Inspector/Risk M3305 Assessor License Number: Date of Inspection: 06!07/2013 http://enT.detma.org/del eadingworknotification.aspx Expiration Date: tba 4/18/2014 24/2014 THU 10:52 PAX NOrthat11pt0n Board Hearma THE COMMONWEALTH OF MASSACIIUSETFS Department of Labor Standards Homepage: www.mass.eov idols '[hank you for your submission. Your confirmation number is: 8185248. A confirmation email has been sent to:abide @abideinc.com. http.//uvr.detma.org/Contimiation.aspx Page I of I 7124/2014 /24/2014 THU 10:53 FAX NOrtharPtOR uoaru neo"L Notification of Deleading Work Department of Labor Standards 19 Staniford Street, 2nd Floor Boston, MA 02114 www.mass.00v/doll Page I of I Department of Public Health Childhood lead Poisoning Prevention Program Donovan Health Building 5 Randolph Street Canton, MA 02021 www.mass.clovidoh/clpop NOTIFICATION OF DELEADING WORK All sections of this form must be completed M order to comply with the notification requirements at M.G.L. C. 111 5 197,454 CAM 22.00 and 105 CMR 460.000,as most recently amended. This Notification Routine Notification submitted at least 10 days prior to project start date is NOTIFICATIONS MUST BE SIGNED, DATED AND COMPLETED NOT LE ED IN THEIR ENTIRETY,INCOMPLETE NOTIFICATIONS Project Information : A proper address is critical. All addresses must be verified through the LISPS database Address Verification House Number: Street Type City: Property Owner/Agent: Owner Address: Second Property Owner/Agent; Owner Address 2 TYPE OF Multi-Family Noon.,; DWELLING: 59 St Northampton Rachel Merrell 59 Summer Street, N n/a Street Summer Name: Unit/Apt 1 Number: Zip Code: 01060 Phone: 413-585-1516 Email: rmerrell @charb Phone 2: Email address 2: Inspection Information: Before starting any work,contractors should check a property's previous lead inspection history at CLPPP Lead Inspected Homes Database Name of Licensed Lead Inspector/Risk: Inspector/Risk,M3305 Assessor License Number: Date of Inspection:. 06/18/2014 Eileen Manlet. http://ewr.detma.org/deleadingworknoti fication.aspx tba Expiration Date: 7/24/2014 /24/2014 THU 10: 53 FAX —. Northampton Boaro nee. DELEADING CONTRACTOR Page I of 2 DELEADING NOTIFICATION FORM DELEADING CONTRACTOR DES-NFICERATE PIS)!SUPERVISORAMD'5AFt 4£NOVATfON iONTRACtOR }THIS SECTION MUST BE COMPLETED BY THE DELEADING CONTRACTOR OR THE MODERATE RISK SUPERVISOR/LEAD-SAFE RENOVATION CONTRACTOR WHO WILL BE PERFORMING THE DELEA DING WORK, CONTRACTOR!NFORM.AT!e!'_______... Contractor Name: Abide,Inc. Contractor P 0 Box 886:483 Shake' Road Address: ------ City: East Longmeadow Stale: MA Zip Code 01028 Contractor Contact Jerry Gray Person: Email: Office Phone: 413-525-0644 - Cell Phone: ebide©ab deinc tom Contractor License Number: DC 1. 001619 Expiration Date: 0825/2014 I� TYPE OF DELEADING WORK TO RE PERFORMED: Class I Deleading Methods(cheek all that apply) AbrasHe BlasU 9 with'ad-misting technique or simultaneous vacuums system(EXTERIOR USE ONLY) '.;... Caus&is(use G methylene MUNRe is pooh/Mod) _-04,4049 Slwkrate Risk Deleadiag Methwts(check all that apply) ,Capping Baseboards Coveeng 1 Liquid Encapsulation Lon Risk°pleading Methods(check all That apply) :..:Capping NsebNNs CC Covering tt_Liquid Encapsulation WORK SCHEDULE: Project Start Date: 08/18/2014 l'' Project Completion Date: 0829/2014.. List the hours the work will be conducted: Start time: lam End Time: 5pm In accordance with Massachusetts General Laws C. ill, sec. 197,454 CMR 22.00 and 1.05 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: 1) Department of Labor Standards, Lead Program,and 2) Director,Childhood Lead Poisoning Prevention to the oCowmg Department of Public Health Notification is also required to be provided hltp://ewr.detmaorg/DeleadingContractor.asp; 7/24/2014 __ ° F4n114+n4-4F" ewI µewwm'vn SIP kuiiwos AWOtlRb+wo Ew+Ew aff, 2wzo AUwaPoakM w s, p1 pue a$OJ aqq FECI ptjsn spW vtiWew 44s5)”21-441"” .'N v1 dpw F RYq (s1P4 Ae eae0 n9N&Notl cngbl.2a� os 00 tbI SSHr Jwe Inluo,sI1a aSSG ylw sa u wPae,l 5 Aa n,n,kMN.'+ail Val a'AViI Kx nro�swJn ® 1:4N a amuizv'e anal ti IV■W T1,1,01{rt.pfi 39Mtl V 9 wl �� �,• ,. ..Fa. ermw.mma:am ini cs mww ., m >.,„, 6i0tATITOe'i.e.rt>°+aa1 �rtmlEIiauIE(oiaaou D-amxleain al 9 0-- Palau.9.1wDrilavq-etxo wKKPlmMq "a4-C2aal, ,V0 1 iosaV 1gml.WRpinJ 4201 V tlVI'Wt uANxEnlSA on rviE F t4 w-. swpav»a+nut.. W R9 YI Al3Y-0w� AiAi6Re00415tAINI SW nom 9Fmtlln ixtmmugsia n TIMOIX DR<WF09 nmrmmxnmSOW1JKIueidus vminmocwix>-wvm1vuwJeaariiiairuxe a5ua�aFisFFkoruasswi. nxu,. mORSS --. - _#01 i� mn aa! ..._ee.. nTwa uOadmYVUON XYd 95 ;Di am' 6i0Z/62N "//24/2014 THII 10: 54 FAX --° Northampton soa o Benz DELEADING CONTRACTOR Page 2 of 2 3)Occupants of the dwelling unit 4)All other occupants of the residential premises, if any 5) Local Board of Health/Code Enforcement Agency Notifications should be submitted electronically thru email to boards of health. Click the link to see a listing of email addresses: Boards of Health Email addresses 6) Massachusetts Historical Commission, 220 Morrissey Boulevard, Boston, MA 02202 Fax(617) 727-5128 If premises is listed on the state Register if Historic Places, this notification must be made upon receipt of an Order to Correct Violations or at least 30 days prior to initiating deleading. By submitting this form,the undersigned hereby states, under the pains and penalties of perjury, that he/she has read and understood the Commonwealth of Massachusetts Deleading and Lead-Sate Renovation regulation, 454 CMR 22.00, and the Lead Poisoning Prevention and Control regulation, 105 CMR 460.000, and that the information in this notification is true and correct to the best of his/her knowledge and belief. Name' Mona Tills Date: 2 07/242014 la 1..8ubmit.3 http:'lewr.detma.org/DeleadingContractonaspx 7,24/2014 '4 .re.waPl a ii l4•' 4I P ex- GI._wre+s vsfiutaw+Paw) bwsy ,6"- pmaa x m�rueSjorma w +aa%r>ti Pua•eauw P'+3ofpp AO^ °P °✓0F�9?"MW um xr+mwe M ftl(xtA R MDKV a61 »M11I >M'1 F v . I ®., i0'.ant a.eowmlt•cVNO) YA'99O Nt 4P i3l[W — ]R.id9B.*ik69 1 c, c�vq eM- N1*4mTAM1+s�+M1nawgnlw.f.. .e a^cunw,a�.: .ao- asAS6w 77 Wswn<vmjxfxclmwxvTmz y,6ef p F0vMr0+R0OCxg1>ti l .rmaU dN fOLHNO,K9V'(4flW3OUXi:. — ND •oaeammalvouv, _�,.,. 4 •=m max. .,»,.,i-WW.':.i rude .anmr,ua• SSCcIch rnwr 111t NO@olva 3e NCx oxk soJ vaigoo NOILVAw93 us"am(sovna3eRs .wf3 npraweefoufxwoDafmr31m3x1Aea3t'ner1m3e3aIx xwlDSVxI. n.ss ntsN .P.ig. . vaTPan DZQOR vogameq;lo& XYd LS ;Oi QHS bid[/CL rthampton Mail-Deleading Job eading Job ssage https://mail.google.com/mail/u/0/vui=2&ik=9954d8032f&view—lt&s... Ed Smith<esmith@northamptonma.gnv> Ike Schnabel<sparke58 @vedzon.net> smith @nodhamptonma gov Ed, :re is the information about the de-leading job I am going to be starting in Florence.Ill be starting sometime after 4/271,The entails tail sanding, de-leading exterior of the building using the following methods,removal,some demolition(removing and replacing clapboards), scrapping noval using a power shaver attached to a HEPA vacuum with HEPA filter All safe practices will be applied.My Deleading Supervisors license#is trth Main St, information is: My working hours at the Schnabel,ite will be Hill Rd,Williamsburg MA 01096. to 6:30 Please feel free to call me if you need any other informs ion. Thank you r your help with this I the best, Doke Schnabel Mon,Apr 13,2015 at 11:15 AM 4/13/2015 11:22 AM