59 Notification of Deleading Work 2014 314 FRI 15:44 FAX — Northampton Board aeattn
Notification of Dcleading Work
Department of Labor
Standards
19 Stamford Street, 2rd Floor
Boston, MA 02114
www.mss.goyidols
Page 1 of 1
Department of Public Health
Childhood Lead Poisoning Prevention Program
Donovan Health Building
5 Randolph Street
Canton, MA 02021
www mass. ov d h dppp
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 CMk 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
15
NOTIFICATIONS MUST BE SIGNED,DATED AND COMPLETED D IN TKELR ENTIRETY.INCOMPLETE NOTIFICATIONS
NOT
Project Information : A proper address is critical. All addresses must be
CSPS database Address Verification
House Number:
Street Type
City:
Property
Owner/Agent:
Owner Address:
Second Property
Owner/Agent:
Owner Address 2
59
St
Northampton
Rachel Merrell
59 Summer St. North
nla
TYPE OF Multi-Family Horn
DWELLING:
Street Summe
Name:
Unit/Apt 1
Number:
Zip Code:01060
fled through the
Phone:
413-5051516
Email: mterrell @charI
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 Humes Database
Name of Eileen Mantel
Licensed Lead
Inspector/Risk:
Inspector/Risk M3305
Assessor
License
Number:
Date of Inspection:
06/08/2014
http:Newr.detma.org'deleadingw o rknotitication.aspx
Expiration Date:
tba
8/1/2014
0L4 FRI 15: 45 FAX "' Northampton Snares neain
DELEADING CONTRACTOR
VON \ Page 1 oft
DELEADING NOTIFICATION FORM
DELEADING CONTRACTOR
OLE MODERATE RISK SUPPRVLSORAfAD-SAFE RENOVATION CONTRACTOR
*THIS SECTION MUST BE DELEADING CONTRACTOR MODERATE RISK
UPERVISOR(4EAPSAFE RENOVATION CONTRACTOR WHO WILL RE PERFORMING HE of EADW .
CONTRACTOR INFORMATION:
Contractor Name: Abide,Inc_
Contactor P.O.Box 856;483 Shaker Road
Addess: -----'
Oa; East Longmeadow Slate: MA J,ip Code: 01028
Contractor Contact Jerry Gray
Person: Email:
Office Phone: 413-525-0644 Cell Phone:
abbe @abitlemccom
Contractor License Number: DC 001619 Expiration Date: 08/2 512 014.®
TYPE OF DELEADING WORK TO BE PERFORMED;
Class 1 Delcadmg Merhads(eheck all that apply)
__ Nix
Abras,a Blasting with wM'm46no re:hnouc or smunareor vacuuming system(E013t10R USE ONLY)
flosses(use ct mettrpene dlertde Is prop Nted)
..-cownng
is daate Risk Reloading Methodslchtck all fhut apply)
Cassano Baseboards
Cwenng
JJ bguid Encapsulation
Low Risk Deleading Methods(abeck all that apply
Levering Baxelaoards
E Covering
linos'EMapsiLOOn
—WORK SCNEDLLEf
Project Start Date: 08/1312014 ® Project Completion Date: 08129/2014
List the hours the work will be conducted: Start Clare: gam
End Time: 5pm
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 ar 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 Program (CLPPP),Department of Public Health
Notification is also required to be provided to the following:
811/2014
http.0ewr.derma.org'DeleadingContNCtor.aspx
014 [RI 15: 45 FAX --- Northampton Board Bealta
DELEADING CON'J RACI OR
Page 2 of 2
3)Occupants of the dwelling unit
4) AIL other occupants of the residential premises, if any
5) Local Board of Health/Code Enforcement Agency
Notifications should be submitted electronically tine email to boards of health.
Click the link to see a listing ef email addresses! Boards of Health`.mail addresses
6) Massachusetts Historical ommis io 02202
220 Morrissey Boulevard, Boston,
fax (617) 727-5128 this notification must be made upon
If premises is listed on the State Register if Historic Places,
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-Safe 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: Mane Tllli .
Date: 081012 i& 'I_-Submit
8/1/2014
httpa/eva.detma.or eleadingContractor.aspx
Wxxr+5+ 3R4Hi o"1
r hnnW�3aFnxi aax6 xm vms3:xv"+KU
1:.,11 mf%'1mW11'M1 maHSt .�
_ .aAmKA1++4iH6rttNHiR1>N
dti4�$VAHSdtflDl'AH6N[)YWS`3T3If}p3d[t {1�t
r.p'"L9. zp uoVexin 'n 4• X -"N'N } 1
3 �
an wµn.�aJAe oy 'EaW,1.l FPS5 n1 e4 'no ^i.
e]YV +MI2 [V CFI J r 'v3 -
1P9+W OA '.SR9Jq la€puoD
`W VM -1u11W+9R11'PJ
\INP0J310T38Y0OThiWOl
.x1,n a,3mo30 919Ma nv.36 0SxtOnp#OP 1At03x •
1dl.0D N3 mwott SNiOdlo-
`� 11SIB arliaaX]Nnoitonnmtn NH9R1X13111A0.O31314110]YHJC(1111 A:Yl4CMla
u-.vaew.y= u,guaer�¢rrav '
NO1)tlN1NOD 9NIOV3130
14110d NOTLV313110N 9N1093330 =i
-
_— -x,.r ea nuxi,rs�or. o
a5ff
_ _ _. 144TraH p roa UO;1U1fl2ON —^-- 'K+3 OE ;ST TUJ 5
/2014 FAT 15: 40 FAX »- Northampton Board Health
TILE COMMONWEALTH OF MASSACHUSETTS
Department of Labor Standards
Homepage: wiw°.v.mass.govidols
Thank you for your submission. Your confirmation number is: 1567500.
A confirmation email has been sent to: abide@abidcinccom.
4LIVVI/UVe
Page I of 1
http:/%ewr.detma.org/Confirmation.aspx 8/1/2014