421 Notification of Deleading Work 2005 I
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Department of Public Beath/Department of Labor&W
N011FICA'TION OF J LEADING WORK
An sebum.f this term mud be completed la order m comply with
the utterance essimiruant..1M.C.L C.111/197,
454 CMR nand 05 Chit 4414104,r mew roomy,ameeded
PR 2 6 2035
Caerertor petfenLer peafM Ifreaed t .Date
Lead neat lespema nets el!l�n a
ADDBESS OFFROJKCT ? p�aeree t v or- mu5r- 'fFvg50uth a ranee pO�V1cc4 F
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(Character's Ilepreeeafati.e)
QELEADING CONTRACTOR
The mdeneped hereby slams,outer the pass ad peaWie..f perjury,Sat■eisbe ha had aad ramaaad the Commonwealth of
MasacSretb Delman Iteg*Ltiaet,154 CMR Ma,W the Lad Pahva4g pssventma sad Camara RegWti.w,105 OAR 4611.400,aid
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Vet ails Adnlinisiratior
VELA FAX TRANSMITTAL
This t aaamLesim is micaded only fu the um of the
privileged,confidential,or protected by law.
All alms are hereby notified that receipt of this message
that any dissemination,dehbutaon,or copying of
This document may rennin information covered=der
Acmnntab$tyAct(PL 109-191)and its various implementing
Healthcare inbroffiionis personal and sessiCve and
information,its bemgprovided to you alter appropriate
patient eathoOatim. You,the rte,me obligated
additional padeatconsent eras permitted by law is
subjects pub application of appropriate santoa
imenediatidy at the tekplione somber than below
person or
does
this communication
dm Privacy
mint be
aodbaiadion
to maintain
pobtbited.
If yen Mn
and de*uy
office to whom it is addressed and any contain information
that is
and•
and
provision
not require
without
sender
Revised 8/7/03
not waive any appliable privilege et eumpGm from divuw,re
is prohibited.
Act,SUSC 552(a),audios the Heath tumoure portability
rcguLtlms and giant bepmteded in aaatdaoaa with those
noted accordingly. If this couespandame contains healthcare
from the paSal anodes circumstances that do
itmnsafe,setae and aofdemisl®er. Redischasme
Unandanizai mdieekmm or failme to maintain confidentiality
w.4 this mm4eondence in arm plasm tatty the
any copies yam tern node- Thant yon.
421
ONFTDENTLAL
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VA MEDICAL
CENTER(Northampton)
OF VETERANS AFFAIRS
N.Main Street
MA 01053-9764
. .
DEPARTMENT
CONFIDENT • • Leeds,
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Pax fhY3 - 5717- Jars /
PLEASE SIGN BELOW AND PAX SACK TO ACgtOF4.anGE RECEIPT OA AlTAC@D.THAMt5
ACHNOWLBOG&d2NTOF RECEIPT:
SJONA1URE
PATE;
�Tient of Public Health/Department Labor&Workforce Dev'elopmen
rho
NOTIFICATION OF DEL,,,ADYNG WORE
Ail sertians of thtsThete mint be completed in order t9 comply wine
do nntmcntiine ragelrementh irMfl.C.lii§197,
454 CAM 22.110 sod 105 CMI(460.000,as most recently mended
AccuTech Insulation &
Contractor performing project Con fr act inn , Inc . Llreaee hV D0001600 Up. 5-3-06
Lead paint inspector Behzad Samimi . Dam of/mpeehim 4-20-05
License* M1726
Esp. Date
ADDRESS OF PROJECT:
street Address 421 North Main St . Apt Numb=
Ciq Leeds , MA 9iP 01053
Prop Department of Veteran Affairs attress 421 Ndrth Main St . Leeds ,MA 0105
Telephone Number 413-5823035
Deaeadinp Method: ot/Ory Sereping> Hest On
Demolition - Caustics
Covering Omer
If-other"seleattd,Pietas earth M
liquid Facaptrodunt
CSeplac onne t
Cheek one: Owcliing is muliitmtly 5ia4o-family ode= Entrance Hallway
Start f7se 7-11-05 7-25-05
Completion-Date
When will work be dmto: AM X P C__, (Speedy dates ml tier) Weekends? N/A
8:OOAM-4:30PM
PrajeetSnpervisorName Anthony Roy r^tm...e/PS 0033(,(, tap,hate 1-3-06
Worker's Compensation Policy Number WC6929778 - currim. GraniteState Insure
la case of emergency commet Gloria Jenkins Teta ( 413 ) 583-5500
(Contracmr's Representative)
DELEADINO(ONTRACFOR
The undersIgned hereby elates,under the pains and penalties of perjury that beishe hnareadand enders/nod the Commonweelthm
Massaehaseita Deiending aeg ilatont,454 GIVER 22.00,and the Lead Poisoning Prevondan and Control Regulot ins, 105 CMR
460A00,and that the information contained m lids notification is time and correct to the heat of his herlamwledge and ballet
Date June 27 , 2005 Signed
Company Name AccuTech Insulation & Contractin Inc.
Addrem 100 State St . P. O. Box 376 Ludlow, MA 01056
Telephone Number 413-583-5500 -
OVER-P
U t5 V_ti rn
AI$2 2005 j GJ
".1AMPTON BOARD OF HEALTH
LTH