17 Notification of Deleading Work 2012 3/22/2011 TILL 16:50 FAX +++ NorthaiiPtnn Board Health l®ouz uua
Abide#11500
Notified:9/22/1r
� b
Department of Public Health&Department of Labor
NOTIFICATION OF DELEADINC WORK
MI Mons of this form mast be completed In order to amply with
the moderation regohementsdM.GL C 11IS197,
454 CMR 22.10 and 105 CMR 460000,as most measly amended
Contractor pert hog project Abide. Inc. Lame DC001619 Esp.Date 825112
Lead pant IU,p,coEileen Manley
ADDRESS OF PROJECT:
Street Address 17 Munroe Street
cityNodhampton,MA
Date of inspection 8/9/11 Uem+eJM3305 Esp.Date TM
Apt Number
up 01060
property owner Passage Holding,LW-Susan Descarge Addreg 23 Munroe Street, Northampton,MA 01060
Telephone limber 413-531-6812
DMeadlna mithea Qt1WWUy Sashimi ❑Heat Gen Ei Ugdd Encapsdont
ODemddon ❑Camam ®Replacement
EiCorerine ❑Other
If"Other selected.Please explain
Check one: Dwelling is mid i.faoiy
Sort Dam 10/10/2011
sktgletWHy I I O16a I I
compktlmDate 10282011
When wO wet be doom: AM 7 PM 5 (Speedy toes at site) Weekends/
Project Supervisor Name Jerry Gray Deena DS003770 EspEste 8/7/12
Workww.Campeau*"racy Number AWC 7 01 3 27 8 01 2 011 corder AIM Mutual Insurance
In amd®ageacyca Frank Tilii Td g( 413 )525-0644
(Contractm4 Repreredadn)
DfnwaDING CONTRACTOR
The ndaslyed hereby states,under lie pdm and paaldn apathy,that bathe Ms read and odersteed the Ca nwalthd
Massachusetts Ddadi4 Regdasiea,454 CMR MAE and the Lad Adman Paemiem ad Contra Refinishes,l CMR MAME od
that the idonaatio contained S Hie nWReadon R tree andd correct to dm best of►0lhar iowedae ad bat.
Sled ✓ tv`
Frank Tilli,Vice President Crap
Date 922/11
company Name Abide,Inc.
Address P.O.Box 886,East Longmeadow,MA 01028
Telephone N®Mr 413-525-0644
OVER-d
/22/2011 THU 16:50 FAX -.44 Northampton Board Health
Page 2 of 2
lav d,VVu
In accordance with Massachusetts Decal Laws C.I114197,454 CMR 2200 and 105 CMH 46►000,satire of the date and webod(t)of
removal or covetbg of last,piaster or otter accsdble materials confining mugeroas lads of had is to be provided and mast be received
by the Mewing agencies,at last 'D't(10)days prior to the beginning of ddeding.
NOTIFICATIONS MAY BE FAXED.
2.
3.
Departsent of Labor,Laid Program,Division of Omnpstionnl Safety
19 Sta®brd Sheet,In Mar,Byte,MA 02114 FAX 6174246965
Director,CYBdhmd Led Poisoning Presets Program
pepadmeat of Palk Health,Donovan Health Building,5 Randolph Sled,Canton,MA 02021 FAX n1.774$700
Occapeb of dwelling weft
All ether occupants of the reddests'premisn,R any
Loral Board of Health/Code Warman*Agency Northampton Board of Health: Fax 413-587-1221
6. Massachusetts Historical Comdrtbn
2T0 Morrissey Blvd.
Boss;MA 02201
FAX(617)727-5120
Of premises are listed ea the State Register of Historic
Plans,this notification mast be made upon receipt of an
Order to Correct Violation or at'east 30 days prior to
initiating preventive dreading)
NOTIFICATIONS SHALL BE COMPLETED IN TTY ENTIRETY,DATED AND 9(20?D-INCOMPLETE NOf EICATIOiS WILL NOT
BE ACCEPTED AND WILL BE RETURNED BY DM DFPARI'MINP OF lLABOR&WORKFORCE DEVELOPMENT.
ESQLZI YOW1 R(N mina or mmlicrmad owners agent will be performing low-risk&leading mode,complete the following):
Pity Omar NOT APPLICABLE Ages(s)
Address
Telephoto Number I )-
I certify Thai have complied with theloming regov®ms of t e C lt of Massachusetts lad Poinnsg Prevention and Crabs ReNStona.105
CMR460.175,br owner/aged low-risk abetment ad amvbDmt I farther certify that l or my agent mil be perfuming the following low-tie activities
(I have drekd all that apply):
appbbg Bgold meeleadamf
eppin6 baseboards resents:dome,rabbet days,shutters
apps n ntnsr dad ddbg emeriti surfaces
I certify that all the infwmebon cmtsmd to this nath heath is to and toned to the best of my maMdac and belief
Date Sled
Revised I2200
Abide#11500
Notified:9)22/11