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421 BLDG 11 Notification of Deleading Work 2006`a, ,ntractor performing project /ra r D4...rtment of Public Health/Department b..,abor&Workforce Development OF DELEADING WORK All sections of this form must be completed in order to comply with the notification requirements of M.G.L.C.111097, 454 CMR 22.00 and 105 CMR 460.000,as most recently amended N/A License# Exp.Date M -170/6 -MA ad Paint Inspector €tl f_t .L Lpni.Nl Date of Inspection License# Exp.Date Bo;ding Room t l ;1,303a gst Number )DRESS OF PROJECT: 4/61141 reel Address 7�(1 lfiGf 1 1 ty eP ep operty Owner \„ 1:i , i f e d i ce I `--elVter Add $r fti dap lephone Number 417.2)—L;( 1`Y OLIO leading Method: Scrapin Demolition Covering "Other"selected,please explain 40 -50 cc/ Zip OIOt).?) rG ress SQYti�P:: . Heat Gun Caustics Other Liquid Encapsulant Replacement heck one Dwelling is multi-family Gmo hen will work be done: AM 7,30 PM 7,00 (Specify times on site) Weekends? -oject Supervisor Name PCAhQ Lcl Cnva\At° License xp.Date orker's Compensation Policy Number I) f7 , Carrier art Date MCA ifii/ Carr Single-family Ocher Her HO 11 c I j I'ce Completion Date c ('o6 case of emergency contact -COMhe etrr 2�q/1NTel.# ( 913 1_CS 4-401-0 :ootrectar's Representative) ( f C&.mj M 1 Cr, 2 30 EJADING CONTRACTOR YI j�{-( c�t.f he undersigned hereby states,under the pains and penalties of perjury,that he/she has read and understood the Commonwealth of lassachusetts Deleading Regulations,454 CMR 22.00,and the Lead Poisoning Prevention and Control Regulations,105 CMR 460.000,and at the information contained in this notification is true and correct to the best of his/her knowledge and belief. ate /' Signed ompany Name ddress elephone Number OVER-t in 2 4 2306 Page 2 of 2 :cordance with Massachusetts General Laws C.III§197,454 CMR 22.00 and 105 CMR 460.000,notice of the date and method(s)of Will or covering of paint,plaster or other accessible materials containing dangerous levels of lead is to be provided and must be received it following agencies,at least TEN(10)days prior to the beginning of deleading. FIFICATIONS MAY BE FAXED. Department of Labor,Lead Program,Division of Occupational Safety 399 Washington Street,56 Floor,Boston,MA 02108 FAX:617-727-7568 Director,Childhood Lead Poisoning Prevention Program Department of Public Health,Donovan Health Building,5 Randolph Street,Canton,MA 02021 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 FAX 781-774-6700 (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) TIFICATIONS SHALL BE COMPLETED IN THEIR ENTIRETY,DATED AND SIGNED-INCOMPLETE NOTIFICATIONS WILL NOT ACCEPTED AND WILL BE RETURNED BY THE DEPARTMENT OF LABOR&WORKFORCE DEVELOPMENT. OPERTY OWNER(If owner or unlicensed owner's agent will be performing low-risk deleading work,complete the following): sperty Owner Agent(s) dress lephone Number_( ;rtify that I have complied with the training requirements of the Commonwealth of Massachusetts Lead Poisoning Prevention and Control Regulations, 105 fR 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 save circled all that apply): applying liquid encapsulant applying exterior vinyl siding citify that all the information contained in th rte Vi]% occ. 104 capping baseboards covering surfaces notification is true as orrect to the best oJ. 'knowle�ije and belie removing doors,cabinet doors,shutters Signed A444_ Department of Public Health/Department of Labor&Workforce Development IS I,NOTIFICATION OF DELEADING WORK All sections of this form must be completed in order to comply with the notification requirements of MG.L C.111§197, 454 CMR 22.00 and 105 CMR 460.000,as mast recently amended ,ontractor performing project License# Exp.Date �} qq .ad Paint inspectori4'R41Q Soul; H Date of Inspection License#M- TIP.Date 1DDRESS OF PROJECT: itreetaddress 9W Nrrh el Ji t+ �N m]b r fdephone Number 413- "4-u0 Li0 Deleading Method: We Demolition Covering If"Other"selected,please explain 110 -50 Ileat Gun Caustics Other C4 IT Liquid Encapsulant Replacement dS ti Ce Check one: Dwelling is multi-family Single-family Other Ce- Start Date 6,I/Ial0c Completion Date Ls( lo4 When will work be d n : AM7.1. PM y.0(/ (Specify times on site) Weekends? Y Project Supervisor Name`��y/'l1Mk _ license# Exp.Date S/%/(l7 Worker's Compensation Policy Number f Y //T Carrier --en: (d2ItTel.# j 1:-)Kg----46/10 In case of emergency contact (Contractor's Representative) , 77j�m1-0Ct303c DELEADING CONTRACTOR The undersigned hereby states,under the pains and penalties of perjury,that he/she has read and understood the Commonwealth of Massadmsets Deleading Regulations,454 CMR 22.00,and the Lead Poisoning Prevention and Control Regulations,105 CMR 460.000,and that the information contained in this notification is true and correct to the best of his/her knowledge and belief. Date Company Name Address Telephone Number Signed OVER-, wtD Or'HEALTH ! . • Paget of 2 In accordance with Massachusetts General Laws C.111 §197,050 CMR 22.00 and 105 CMR 460.000,notice of the date and methods)of removal or covering of paint,plaster or other accessible materials containing dangerous levels of lead is to be provided and must be received by the following agencies,at least TEN(10)days prior to the beginning of deleading. NOTIFICATIONS MAY BE FAXED. 3. 4. 5. 6. Department of Labor.Lead Program,Division of Occupational Safety 399 Washington Street,51k Floor,Boston,MA 02108 FAX:617-727-7568 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/Cod E f cem t Ag cy 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) NOTIFICATIONS SHALL BE COMPLETED IN THEIR ENTIRETY,DATED AND SIGNED-INCOMPLETE NOTIFICATIONS WILL NOT BE ACCEPTED AND WILL BE RETURNED BY THE DEPARTMENT OF LABOR&WORKFORCE DEVELOPMENT. PROPERTY OWNER(If owner or unlicensed owner's agent will be performing low-risk deleading work,complete the following). Property Owner ) Agent(s)- Address Telephone Number ( )- I certify that I have complied with the training requirements of the Commonwealth of Massachusetts Lead Poisoning Prevention and Control Regulations,105 CMR 460.175,for owner/agent low-risk abatement and containment. 1 further certify that I or my agent will be performing the fallowing low-risk activities (I have circled all that apply). applying liquid encapsulant applying exterior vinyl siding capping baseboards covering surfaces I certify that all the information contained in this notification is true Date r) 08/04 Caa u�� )te �` ern 3310 4; Signed removing doors,cabinet doors,shutters nett to the best ooknowledgtnd belief �e •e ic VAy 110-1-iQeci tic; U about -1-146 fob , but w& it \usene(76. C€ ce OM lY er em y ;Ger mho moni-roes oc .