11 Deleading Notification 2011./12/2011 L2:31 IrAT 4135850417 FARADISF.. COPIES 10002/00'2
-------.- . ,ay.,c nation- t-ru1dL1WO Lean Poisoning Prevention Program
Owner/Agent Deleading Notification
Please complete all sections of this form clearly./atom pieta or Illegible forms will be returned
Lead Paint Inspector )/9-vcei /y/nt 'jv/af/,yt
Property Owner IA)t C(r ir.» r 7/c
Property Owner's Address /C f/r /,fic;.a c if 0,no ilpt
License M/17/4/7/
ifitiF,r IL mg
Authorized person perfuming work Tat nit ovc
Address of authorized person
Telephone Number
13e �C 13cy/c
Ar 4 e._.Jt u
Inspection Date /9 14///
Zip Code aid 3&
Y 70 PI
Lia*/Auth.M o0167$?rqm
Zip Coded/O/„n
Address where the work will be done:
Building Name(if any) 1/ /)11Lti Rot <- :- a floor as
Street Address It 7rt c - r.,-c. <erzta at- Apt No_
City N f-ru tiww_ Zip Code CVO/C/ The property is a Jzmuhi-family
Deleadloe Methinks):
O Making paint intact(high
risk)
o Demolition
o Scraping
Component
removal replacement
o Dipping
a Making paint intact
(moderate risk)
o Liquid eocepeulant
.t Covering
o Capping baseboards
/7/7.P4-
single family.
• Applying vinyl siding on
exterior
jet Component removal(low
risk components) -
o Other
The work will begin on L/4/thand will finish by 231/Y1(.The work be done in the am_pm or�aweekdys.
In Case of Emergency Contact A. C C ie.
Daytime Phone y/3- 5 YY Jon 771 Evening Phone V 7 -9 fl'
raft per
Property Owner mast complete and sign the following information:
rtify that only authorized persons who have complied with the training requirements of the Massachusetts Lead Poisoning
remise and Control Regulations, 105 CMR 460.000,will conduct deluding work.I further certify that the authorized
on(s)will not exceed the scope of his/her authority and will be performing only those activities circled above.All of the
nation contained in this document is true and correct to the best of my knowledge and belief.
Date ////////' Signed r'
The following people/agenda must be notified ten days before/beginning work: •
1. Occupants of the dwelling unit
2.All otter occupants of the residential premises„ if any
3. Childhood Lad Poisoning Prevention Program,DPH Fax(617)284-8436
56 Roland St.,Boston,MA 02129.1235
4.Asbestos and Lead Pmgtam,DLWD
399 Washington St.,Boston,MA 02108 Fax(617)727-7568
6. Local Board of Hahh/Code Enforcement Agency
•ltthe bone is on the Srae Regina of Hinman%aces,all the MA Historical Commission at(617)727-847A