319 Notification of Deleading Work 2013/25/2012 THU 14:24 FAX -.. Northampton Board Health
Department of Public Health&Department of Labor
NOTIFICATION OF DELEADINC WORK
All sections of this form mast be completed N order to comply with
the notification requirements of M.G.L.C 1110197,
454 CMR 2200 and 105 CMR 460.000,as most recently amended
:ide Jobe:2543
Nifed On:10R5'12
Contractor performing prided Abide Inc license#00001619 Exp.Date 8/75/7019
Lead Pabst Impeder Scot Balfour Date of Inspection 9/7/2012 Chaise#M1143 Exp.Date TBA
Atwater Associates
ADDRESS OF PROJECT.
t =n Housing Authority-319 South Street
Apt Number
100U1/UV[
City Northampton MA Zip 01000
property Owner rtbararpo_u=c n0 4 li nnnty Addrm 49 Old South Street Northampton MA 01000
Telephone Number 413-584-4030
Deleading Method:O Wet/Dry Scraping 0 Hcat Con 0 Liquid Emapealant
ODenolltien ❑Canada 0 Replacement
jajCoveetng 9Otber
If"Other selected,pose explain
Check ewe: Dwelling is node-family
Single-family t T— l Oder
Stec :ate 11/7/2012 Completion Date 11/9/2012
Wen"II work be done: AM 7 PM 5 (Specify times on site) Weekends? TBA
Project Sapervbo(Name Jerry Gray Licensed 06003770 Exp.Date 8/2013
Worker's Competition Pokey Somber AWC7013278012012 coma. AIM_Mutual Insurance
In case ofemergeleyentact Frank Tilli, V.P. Td-#_(413 ) 525-0844
(Contractor's Representative)
DLUSAIShlaCIINIKACTOS_
The nderegned hereby meta,ands the pains and penalties«perjury,east be/she her nod and understood the Commaawealth of
Maenehameb Ddnding RagWdau,454 CMR 22.00,and the Lead PaimMst Pme®ttn and Control negations,MI5 LMR 460.000,and
tbet the Information contained in tide notification is trae and correct to of blather knowledge and Dellef.
Date 10.25.2012 Sigaedl
Frank 11111,V.P.
Company Name Abide for
Address P O Box 888 483 Shaker Road Fast Lnnameadow. MA 01028
Telephone Number 413-525.0844
hide Job#12543
lotified On:10/25/2012
OVER-.
5/2012 THU 14: 24 FAX -.. Northampton Boa a aeaxtn
Page 2 of 2
In accordance with Massachusetts General laws C iii§197,454 CMR 22.00 and 103 CMR 460.000,notice of the date sad method(%)of
removal or covering of paint,plaster or other accessible matwiah containing dangerous leede of had Is to be provided and mast be received
by the following ageatlea,at least((10)days prior to the beginning of debarring,
NOTIFICATIONS MAY BE FAXED.
L
2.
3.
4.
S
6.
Department of Labor,Lead Proven,Division of Occupational Safety
19 Safford Street,I"Floor,Bone",MA 02114 FAX:6174266965
Director,Childhood Lead Poisoning Prevention Program
Department of Public Health,Donovan Health Holding,5 Randolph Street,Canton,MA02021 FAX:7814746700
Occupants of dweldts unit
MI ether oceapank of the rmtdeatial premises,H any
La..IBoardofHalw/Code Eafmttmemt Agaey Northampton Board of Health F#413-587-1221
Massachusetts Historical Commission
220 Morrissey Blvd.
Baton,MA 02202
FAX(617)727-3128
(if premises are listed on the State Register of Historic
Places,this notification mast be made upon receipt of an
Order to Correct Violation or at least 30 days prior to
initiating preventive ddndin)
NOTIFICATIONS SHALL BE COMPLETED IN THEIR ENTIRETY,DAM AND SIGNED-INCOMPLETE NOTIFICATIONS WILL NOT
BE ACCEPTED AND WILL SE REITJRN6D BY TDE DYPARTMPXT OF LABOR&WORKFORCE DEVELOPMENT..
1YOW F,g(If owner ortmlitmed owner's agent will be performing low-risk ddmdatg wank,complete the following):
Property Owner Ageing%)
Address NOT APPLICABLE
Telephone Number ( )-
I certify that I have complied with the haling requhwah of the Gnamnweal h of Massachusetts Lad Poisoning PrevaOon and Control Regulations,105
CMR 460375,for owcedagef kw-risk abelmeot and mobinoat. I further certify that or my agent will be performing the followng low-S raivites
(I have circled all that apply):
appiying liquid encwWntat capping baseboards removing doers,cabinet dome,shutters
applying Weiler vayl siding cowing=faces
1 certify that all the information contained in this notification is has and carat to the bad of my knowledge cod belief.
Date Signed
Revised!72007
Chide Job#12543
Edified On: 10/25/2012