144 Notification of Deleading Work 1996 CObIMON4]T'ALTH iS:SS:+CN";:_!�-_ .
Department of Labor 6 IndusLr_ea aad ;.at'.. . _ i .
NOTIFICATION OF CLLEADIN7 WORK
vith the notification - - n : -
454 d 22.00 and 105 aft .6C.So) i o- u-
CY t ly asco ... .
FILE :CIC Ea
John i Licence $i o.
Contractor performing project /,�/I /•CL %?4=�. _r/—{/I—//—(L
Lead Paint Inspector _ (/dalle/_l -.<Ll�+t` ice:.-, k 3/5T
-
r 14w-risk delcading work is being
,p..,t'/ owner
,.t tress of Project
ding flame (if any) / �(
t
Address ca/i7/V /7 5/7( L'
Deleac tg method:
n2
Scraping I'.cn" 4Ps
,.quid ceusulant /Covering � .ee� ao:.'-1-=_: placer:ea )
i "O:he selected, please explain
dare 1°�/ ct. '-utple.ron late it:////rn"
will work =e done: AN "'g- 4 yes
_.
Project Supervi r c's name / Gt-Cr//yid _ `. OCG76-t
Property Owner fl SUSG<��/ _ /°rES
a/',_ v Sr/ �J
tv _7 e /9
._ lephone ( Pi—( '.z;/ /
. r case of emergency co. tact 16il5K2.1— CC/LC/hey -.
]hone : day V/3 6;0 ? rcoc s /3 5-„12
GddCeSS
c/o
LTl I !.1(nrt loading Pni .;i : Yl
PUN; aith, 420 .4rtantl'l AV,
e s & Lead P.agram
of C
Lamar 4 indosinn
i00 Cambridge Street
02202
a!-nto.•trs Ili-tr.tical CoINpISS:)O
_2o Nut:i:75,y DIv.I.
celeadxng Contractor
undersigned hereby states, under the ; dint a:rl pr. ,,,;tie; ,
he has read and understood the Conuri,o:wealth :.f Massar,l.'stet rfl
lations, 451 CMR 22. 00 and Leading r.
Poi to:.. :. j l,..i„a•
iations, 105 CMR 460.000, and that the ts:at.:c cl
cation is true and correct to the he
t I i„Lct 1nowlee , _
'4/*
Property ounce tit w.,er or unit.
TitJeg
�cexia c�,-r..
L2ac /_Lt'GC't /Ctot ZI
I certify that I have complied with the training requirements of the
Commonwealth of Massachusetts Lead Poising Prevention and Control !,.:.culati •.:
105 CMR 460.175, for owner/agent low-risk abatement and crutainr;ent . -
further certify that I or my agent will be performing
the following low-risk activities (I have circled all that apply/ :
ai lyim.t .
alta;ifig >. stint V ioyl ...,...t,,•.t .
I tr. inM1nma. t.
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