25 Notification of Deleading Work 2012 Jul201208.16p Kevin C.Netto 413-203-3025 p.2
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madame with Massachusetts Ce.u..al Laws c. III 5 197. 454 CMR 2L00 and 105 CMR 460.000, notice of the die and
shcd(s)of r moval or covering of Wit.piaster or deer accessible materials omraming dangerous levels of lead is to be provided
d most be received by the following pawns,at o-ast-tea rm)davt nrien to the beginning of 4deading.
Occupants of the dwelling unit
MI other oxUERMu of the residential premises, if any
Director. Childhood Lead Pcisonire Prevention Program
Department of Public Health, CO Atlantic Avant, Boston, MA 02110
Director. Asbestos and lead Program
Department of labor and fathmties
Room 1106, 100 Cambridge Street.
Boston,MA 02202
Local Board of Health/Code Enforcement Agency
Massachusetts Historical Cammmisska.
220 Morrissey Blvd
Boston,MA 02125
Fad
'78\-lly-bIOC]
Fax(617)4`2_7-7560
Vab-bVborj
Of premises is fisted m the Sure Regina of HStoric Places this notification
must be made upon receipt of an Order To Correct Violations or at leat 30
days prior inkjet' he preventive&leading.)
Fax(617)727-5128
ithanB-Cmvmcta
t mdetmgoed bereby states,under the pain and mashies of perjury,that le/she has mad and understood the Commonwealth
Masacims tits Dekadiog Regulations, 454 OAR 22.00.and Lead Poisoning Psevemioa and Control Regulators, 105 CMR
0.000, and that the information contained in this notifica fe tion_is true and correct to the best of bisibet'knowledge and belief.
ate -t-ao'a Sigad: e' ` /t%
Tick r
Company 'Skei4 <. C•NP
r ray owner Of ovmer or unlicensed owner's agent will be preforming low-risk delediag work)
certify that I have complied with the training requirements of the Commonwealth of Massachusetts Lead Poisoning Prevention
id Control Regulations, 100 CMR 460.175. for owner/agent low-risk abatement and containment. I further certify that l or
y agent will be performing the following low-risk activity(I have circled all that apply):
applying liquid encapmdain capping baseboards
applying exterior vinyl siding covering surfaces
removing doors,cabinet doors,shutters
airy that all the information contained m this notification is tore and correct to the but of my knowledge and belief.
ate- Signed:
IWPsaaSIDIMPORMIV LNOTSHt1 6a.xa95
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