185 Notification of Deleading Work 2016 _siz vro c+`
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08/12/2016 PRI 16:38 FAX Northampton Hoard Health 2002/003
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a/12/2016 DELEADING CONTRACTOR /4 5 i
Oef DELEADING NOTIFICATION FORM
DELEADING CONTRACTOR
DLS-MODERATE RISK SUPERVISOR/LEAD-SAFE RB40VATION CONTRACTOR
•THIS SECTION MUST BE COMPLETED BY THE DELEADING CONTRACTOR OR
ve,
M/o reV ee
MODERATE RISK
SUPERVISOR/LEAD-SAFE RENOVATION CONTRACTOR WHO WILL BE PERFORMING THE DELEADING WORK.
CONTRACTOR INFORMATION
Contractor Name: Abide Inc.
Contractor PO Box 866, 483 Shaker Road
Address:
City: East Longmeadow State:;MA
Contractor Contact deny Gray
Person:
Zip Code: 01028
Office Phone: 4135250644 • Cell Phone: 4135250644 Email:
maiaaatxdeinc.com
Contractor License Number: ADC • '. 001619 Expiration Date: 08/25/2016
TYPE OF DELEADING WORK TO BE PERFORMED
Class I Delnding Metods(check all that apply)
WA
Abrasive Basting with vier-misting technique or simultaneous vacuuming system(OR96OR USE ONLY)
Caustics(use of nnth 1edaoride is prohibited)
a Cursing
Moderate RiskDdndlag McWOds(cheek all that apply)
N/A
Capping Baseboards
EJCovering
a Liquid Enrapnlation
Low Risk Deieading Methods(eheck all that apply)
WA
111 G3 ag ng Baseboards
u Covering
fs Liquid Encapsulation
WORK SCHEDULE
Project Start Date. _O 122/2016 Project Completion Date: 06252016
List the hours the work will be conducted: Start time: 1 7:00 AM • End Time: i 5:00 PM
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 arressible 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,
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03/1Z/2016 PRI 16:39 PAX
/
Northampton Board health
Nalcatim S Deleadrp Wok
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Department of Labor Standards
19 Stanford Street. 2nd Floor
Boston, MA 02114
w w.mass.gov/doll
Department of Public Health
Childhood Lead Poisoning Prevention Prognvn
Donown Health Building
S Randolph Street
Canton,MA 02021
tvtvw ngss,gov/dvh/clnno
NOTIFICATION OF DELEADING WORK
All sections of this form must be completed in order to comply with the notification requirements of
M.G.L. C. 111 s 197, 454 CMR 22.00 and 105 CMR 460.000, as most recently amended.
This IRoutineNotifiation • submitted at least 10 days
prior to project start date
NOTDICATIONS MUST BE SIGNED,DATED AND COMPLETED IN THEM ENTIRETY.INCOMPLETE NOTIFICATIONS WILL NOT BE
ACCEPTED.
Notification is
State MA
Project Information :A proper address is critical.All addresses must be verified through the USPS
database Address Verification
House
Number.
085
Street Type [Ave _•J
City: Florence
Property
Owner/Agent:
Owner Address:
TYPE OF
DWELLING:
Second Property
Owner/Agent:
Owner Address 2
Street Name:
Unk/Apt
Number.
Zip Code:
/Matthew Soycher
1185 Spring al
Simla Fa•
TYPE OF DWELLING,
2:
• '
'Spring Grove
Phone:
Email:
Phone 2:
Email
address 2:
1413-992-71176
hattsoycher/t4
i
Inspection Information: Before starting any work, contractors should check a property's previous lead
inspection history at CLPPP Lead tnspected Homes Database
Name of Licensed Lead
Inspector/Risk:
Inspector/Risk Assessor License
Number.
'Eileen Marley
hap/lexrAama.org'da'eedrgnarknolialkeaNN7ASINAUICOMettCookieSipparF1
12
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8112/X116
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THE COMMONWEALTH OF MASSACHUSETTS
Department of Labor Standards
Homepage.mtw.maas.g rl�dols
Thank you for your submission.Your confirmation number is:3420902.
A confirmation email has been sent to:maria@abideinc.com.
Continue
Finish
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