184 Deleading Notification 2014 Department of Public Health-Childhood Lead Poisoning Prevention Program
Deleading Notification
Please complete all sections of this form clearly.Incomplete or illegible forms will be returned.
Lead Paint Inspector r^'�«7°"3OASt
Property Owner p,Jt>att.o CHtaE_b}
Property Owner's Address %- - -▪• ewe .n .
License#^"^-1.10€
Authorized person performing work: P c FQ-t0
Address of authorized person (ya- Crk et Pe r c .a»-.--) .t YrrA
Telephone Number('fe,) a3-7 . [ 1
Address where the work will be done:
Building Name(if any))
Street Address (o. t•-)
City Pr-o 24,u cam.
Floor
v 1i-1 .5` t)pt No.
Zip Code 6 1 O Ce3 The property is a •/multi-family single family.
Deleading Method(s):
Inspection Date <u' a-3.1 LE
Zip Code 010(09-
Lic#/Auth.#
Zip Code oto'S3
Making paint intact(high risk)
Demolition
Scraping
Component removallreplacement
Dipping
❑ Making paint intact(moderate
/risk)
e Liquid encapsulant
❑ Covering
❑ Capping baseboards
❑ Applying vinyl siding on exterior
❑ Component removal(low risk
components)
❑ Other:
The work will begin one,Ii1,Xt and will finish by .The work be done in the ✓ am'✓pm or /weekends.
In Case of Emergency Contact/xi-Fa-et) etioaTrit_t-a-ro -
Daytime Phone .4 -s a3- oaLaQ Evening Phone ct(h
ie Property Owner must complete and sign the following information:
ertify that only authorized persons who have complied with the training requirements of the Massachusetts Lead Poisoning
:vention and Control Regulations, 105 CMR 460.000,will conduct deleading work I further certify that the authorized
:son(s)will not exceed the scope of his/her authority and will be performing only those activities indicated above. All of the
brmation contained f.
in/ned in this document is true and correct to the best of my knowledge and belief
��/ N Signed andie /
The following people/agencies must be notified ten days before beginning work: *
Occupants of the dwelling unit
All other occupants of the residential premises, if any work will be done in the common areas
Childhood Lead Poisoning Prevention Program,DPH Fax(781)774-6700
5 Randolph St,Donovan Building
Asbestos and Lead Program,DL W D
19 Staniford Street, 1"Floor, Boston,MA 02114
Local Board of Health/Code Enforcement Agency
*If the home is on the State Register of Historic Places,call the MA Historical Commission at(617)727-847
Fax(617)626-6965