108 APT#C4 Deleading Notification 2003 ABIDE, INC. PROJECT # CJ 3CIZCo
COMMONWEALTH OF MASSACHUSETTS
'Department of Labor r Industries and Department of Public Health
NOTIFICATION OF DELEADING WORK
All sections of this Lots nest be completed ka order to comply
•Lth the notification tegultvrnts of H.O.L. <All 5 197,
4S4 ChM 22.00 sad 105 ad. 460.000 as most recently amended
FILE nmaaEa•
Contractorperfonuing project ABIDE, INC. (Frank Tilli) license
Lead Paint Inspector
/lie; 1 iii cc.r41141k
Exp.date
<AGEHCI USE)
DC001619
1/11/03
License w 3I o
Date of Inspection (q)/oO
If low-risk deleading work is being performed, complete the
Property owner Agent(s)
Address of Project
Building Name (if any)
Street Address
city
s0 .7.11
ST •
AleRTn At.tP(ON
Deleading Method:
Liquid Encapsulant
If "Other" selected, please explain
t fry Scraping Heat Gun
Demolition
following line:
Floor
Apt. No
Zip
Caustics
R placemenc � Ocher
c -4
dI%n
Check One:
Start date
dwelling is mulct-family 1/
e19103
When will work be done:
Single family
Completion date
—7 :00— P-M. 7'00
81 )S103
Project Supervisorc`s name Robert P. LaMountain
Properly Owner �yyt,-lit Cau.sr
A- S$rf4�
Address
Weekends? 5./e.5
License A DS3605
Cily nI10r1Y14m OrN State 11.4A__ Zip CJl()(
Telephone — 585_ -Y�
In case of emergency contact Frank Tillt , President
phone: day 413-525-0644 evening 413-
lover)
- 1 2003
)
aVpto\cc�.ao
Vial ZVVO JUL 10:00 rAA 410 ana vela ADIUL I.W WJVVU VVl
a^
In accordance With Ml. .clv5etta General Laws c. 111 S 190 c`e 22. ono 105 CM 460.000 notice
or the date and methods(%) of removal or covering of paint, plaster or other occessible materials
u
containing dangerous levels of lead is to be provided and must be received by thn following
persons, at least ten (10) day. prior to beginnln0 of deleading.
Occupants of the dwelling unit
All other occupants of the residential premises, if any
Director, Childhood Leading Poisoning Prevention PCOOram Fat (617) 284.'8410
Department of Public Health, 470 Atlantic Avenue, Boston, MA 02110
Director, Asbestos k Lead Program
Department of Labor a Industries
Room 11006, IDD Cambridge Street
Boston, MA 02202
Fax (617) 727-7562
Local Board or Health/Coda enforcement Agency( C X1'1 't���a,�� COK lyf.�" 587-1221
Massachusetts Historical Commission
220 Morrissey Blvd.
Boston, !m 02125
Deleading Contractor
(If premises is listed on the State Registe,
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 deleedLm)
F (611) 127-5129
The undersigned hereby states, under the pains and penalties of perjury, that
he/she has read and understood the Commonwealth of Massachusetts Deleading
Regulations, 454 CMR 22.00 and Leading 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 �2S le -�1
Signed: I �4t'F/r ( f Frank Ti lii
Tale: President
Company: ABIDE INC.
Property Puler (if owner or unlicensed owner's agent will be performing law-risk delved lnu Wilt
I certify that I have complied with the training requirements of the
Commonwealth of Massachusetts Lead Poising Prevention and Control Regulations,
105 CMR 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 (I have circled all that apply) :
applying liquid encapsulant
applying exterior vinyl siding
removing doors, cabinet doors, snorters
capping baseboards
covering stn face
l certify that all the information contained in this notification is true and eurrert u. the
best of my knowledge and belief.
Date:
REV 10/12/95
Signed:
ABIDE, INC. PROJECT # X13 1 2C,
lob 0 m sc., APT C - y