284 Notification of Deleading 2011 Department of Public Health Sr Department of Labor
NOTIFICATION OF DELEADING WORK
All sections of this form must be completed in order to cosiipl4.4th
the notification requirements of M.G.L.C.111§197,. t s 2011
A M 1 a
454 CMR 22.00 and 105 CMR 460.000,as most recently amended
rtractor performing project h-j u s t i ll[ ({)I/21(l//!-/ r a r h i c e n s e a /)e L'ij]I of Exp.Date /.v /-_lT'/ /
d Paint Inspector(//1�/1I: t 1/1ipr Date ofln�spection/l�/1)//U License#4' Exp.Date 47i',-)///
DRESS OF PROJECT:
eet Addre Apt.Number
y Jl&nM1i/ /� /, <y ) /� v 1
perry,Owner C/llzgdlxt1) ij.l'Lfdvr Address 44 /p'h/l'IJI J1/c/(i)(�1&'l4
ephone Number LII,J-2)11 ' I�LJ
Zip C/(202,
cading Method:0 Wet/Dry Scraping
ODemolition
DCovering
Diller"selected,please explain 'WtR Q"Ui
0 Heat Gun O Liquid Encapsulant
DI Caustics 0 Replacement
Other
eck one Dwelling is multi-family
/ 11 X bci l
rt Date
en will work be done: A/Ms 1 PP,My4
ject Supervisor Name Ira .[d('
rker's Compensation Policy Number 4'(,6.b 11/GI
ase of emergency contact Vd ink t('ll1/5j
Single-family
Completion Date
(Specify times on site) Weekends?
Other 1
/3 / I oil
License#J i.1 W06"it Exp.Date /////-0/..)„,
ntractor's Representative)
LEADING CONTRACTOR
undersigned hereby states,under the pains and penalties of p
ssachusetts Deleading Regulations,454 CMR 22.00,and
t the information contained in this notification is true
e A // / /7 ,,}} / (/�p p
npany Name td(/.Sfr/lL etrirti! tii g„JI 11/1 l( /f in
Tress .1 Alh�J/)(& fl!/i7b{i/ �� h9A
/ 710-1,
ephone Number 'AIL kit
Sign
Carrier Sit.///Il tiSJ]ns. to.
Tel.# e//j ) l.q'
hat he/she has read and understood the Commonwealth of
oisoning P 'on and Control Regulations,105 CMR 460.000,and
/her knowledge and belief.
to the b
OVER-1
Page 2 of 2
cordance with Massachusetts General Laws C.ill§197,454 CMR 22.00 and 105 CMR 460.000,notice of the date and method(s)of
val or covering of paint,plaster or other accessible materials containing dangerous levels of lead is to be provided and must be received
e following agencies,at least TEN(10)days prior to the beginning of deleading.
IFICATIONS MAY BE FAXED.
Department of Labor,Lead Program,Division of Occupational Safety
19 Staniford Street,In Floor,Boston,MA 02114 FAX:617-626-6965
Director,Childhood Lead Poisoning Prevention Program
Department of Public Health,Donovan Health Building,5 Randolph Street,Canton,MA 02021 FAX:781-774-6700
Occupants of dwelling unit
All other occupants of the residential premises,if any
Local Board of Health/Code Enforcement Agency
Massachusetts Historical Commission
220 Morrissey Blvd.
Boston,MA 02202
FAX(617)727-5128
(if premises are listed on the State Register of Historic
Places,this notification must be made upon receipt of an
Order to Correct Violations or at least 30 days prior to
initiating preventive deleading)
IFICATIONS SHALL BE COMPLETED IN THEIR ENTIRETY,DATED AND SIGNED-INCOMPLETE NOTIFICATIONS WILL NOT
CCEPTED AND WILL BE RETURNED BY THE DEPARTMENT OF LABOR&WORKFORCE DEVELOPMENT.
PERTY OWNER(If owner or unlicensed owner's agent will be performing low-risk deleading work,complete the following)
erty Owner Agent(s)
thane Number ( )-
ify that I have complied with the training requirements of the Commonwealth of Massachusetts Lead Poisoning Prevention and Control Regulations, 105
460.175,for owner/agent low-risk abatement and containment. I further certify that I or my agent will be performing the following low-risk activities
w circled all that apply):
applying liquid encapsulant
capping baseboards removing doors,cabinet doors,shutters
applying exterior vinyl siding covering surfaces
ify that all the information contained in this notification is true and correct to the best of my knowledge and belief,
Signed
:ed 12/2007