108 Notification of Deleading Work 2014 2013 TUE 10:03 PAX --■-• Northampton Hoard Health ILitausiuu,
de Job#13521
ified: 11/06/13
r#1: 11/19/13
dractor performing proled Abide
Department of Public Health&Department of Labor
4 paw impeder Nell T. Shecrallah
NOTIFICATION OF DEIRAIHNG WORK
MI sectioas of this form nut be completed in order to comply with
the notIlleadon reqatramob of M.G.L.C.1111197,
454 ChM 22-00 and 105 CMR 460000,as most rectally amended
Liam p DC001619 itspiDate 8/25/2014
I1RESS OF PROJECT:
tet Address 108 South Street
y Northampton.MA
Date of Impection 6/1100 Lkape#13170 Exp.met TBA
Apt Number B-14
Zip 01060
vary Oner Smith College Rental Housing Atkins. 126 West Road, Northampton, MA 01063
„beam/tab, 413-575-1562-Ray of Wischhot Construction
ending Method:RI Wet/Dry Scraping 0 Heat Can 0 Liquid Eneepsolat
ElDemeltdoz 0 Caustics al RehiSeelneet
0Ceocring Ei Other
otate ateaat eicarc explain
eck dam Dwain is multial#Y1 xx I Sinee-ballib: I Other I
rt pow 11/25/2013 canoes!,Dm 11/29/2013
len will work he dont AM 7 114 5 (Specify ulna on eke) Weekends? TBA
dect Supervisor Name Jerry Gray mope pDS003770 Exp.pot 8/6/2014
mimes comp,matiospounN,,„,ba.AWC7013278012013 came AIM Mutual Insurance
we of mententycomwe Frank Tilli, V.P.Abide Inc. nu(( 413 ) 525-0644
extractor's Repreentadve)
lLLBliKtCHIERACIHR
e undersigned hereby stater,wader the pales and pmaltin a palmy,that be/she has read and understood the Conemarrealtis of
usachnseds Deleading Repast:one,45404K 22.00,and the tmed Pokey*Prevendoo and Control Regulations,105 CAR 460.010,sad
it the Information coatakeed la thh notifkation is Moe sad correct to the best of Isisfier knowledge and bend.
it 11/1912013
Frank Tilli,VP
=pony Name
Abide Inc.
[dress P.O. Box 866,483 Shaker Road, East Longmeadow, MA 01028
1,0„,„Nanba. 413-525-0644
ide Jot413521
titled: 11106113
v/P.: 11/19/13
OVER—)
013 TUB 10:04
Northampton Board Health vuv °'
Page 2of 2
:ordaace with Mnaehuette General Lane C Ill§197,454 CMR 22.00 and 105 CMR 460.000,nods H the date and method(s)of
vat or covering of paint,Fluter or other=sale materials coatabing dangerous Inds of lead is to be provided and zest be received
totowlag agenda,at last]Ui(10)days prfar to the beginning of ddeadiag.
IFICAITONS MAY BE FAXED.
Department Labor,Lad Program,Division of Occupational Safety
19 Staulford Street,In Floor,Hosts,MA 02114 FAX 617-6266965
Director,Chldhood lead Pdsodng Prevention Prograze
Department of Public Health,Donovan Health Building.5 Randolph Stmt,Canton,MA 02021 FAX:7g1.7744700
Occupants of dwelgnt unit
AU other occupants of the residential premiss,If any
Local Board ofHdth/Code Enforcement Agency City of Northampton:413-587-1221
Mauachusetbs Historical Columba"'
220 Mmalnry Blvd.
Bastes MA 02202
FAX(617)727-5128
(if premiss are listed oe the State Register of Historic
Places,this aottertloe sot he made open receipt of an
Order to Correct Violetioos or at least 30 days prior to
:inflating preventive(Meaning)
(F1CATtONS SHALL BE COMPLETED THEM E1111REIY,DATED AND SIGNED-INCOMPLETE NOTIFICATIONS WILL NOT
CCEPTED AND WILL RE RETURNED BY THE DEPARTMENT OF LABOR&WORKFORCE DEVELOPMENT.
nsWTY OWATER(If owner or untanned owner's agent will bepafc oh,g low-risk deleadbg wok complete the following):
sty Owner Agead')
em NOT APPLICABLE
,hone Number ( )-
ifs,tbstI have complied with We training rspnmenh of the Commonwealth of MasathvrLU)ad Poisoning Prevention and Control Reguled's,105
.460.175.*,r ownedagmi ow-tsk abatement and amen®mt l further certify that D or my slat will be performing the following bw.rkk activities
re circled all that apply):
applying ENNW enapsWat
eappivg baseboards removing does,cabinet douse,shutters
applying exterior vinyl sdlnt covering surfaces
ifs,that all the information contained in this notification is flue and coma to the ben of my lm and d belief.
Skald
d 1212007
deJob#13521
ified: 11/06/13
41: 11/19/13