17 Deleading Notification 2003 p
Department of Public Health/Department Of Labor & Industries
NOTIFICATION OF DELEADINO WORK FILE NUMBER
Alt sections of this form must be copteted in order to comply with
the notification requirements of M.G.L.C. 111 § 197,
454 CAR 22.00 and 105 CMR 460.000 as most recently amended
Contractor performing proj ect((e� Nit License # XAW�Sxp. DateS-a.' )-C`\
Lead Paint Inspector 1- .S \Rr\-\c4Ce. License 0 NhrNTNA
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 1 have colplied with the training requirements of the Cosmmwealth of Massachusetts Lead
Poisoning Prevention and Control Regulations, 105 OIR 460.175, for owner/agent low-risk abatement and
cantairwent. I further certify that I or my agent will be performing the t-following low-risk activities (I
have circled all that apply).
applying liquid encepsulant capping baseboards removing doors, cabinet lfgagal applyingexterior vinyl siding covering surfaces lI ji
I certify that all the information contained in this notification is rue and Parr t to the-tiest of myL {
knowledge and belief.
".AMPTON BOARD OF HEALTH
Date:
Signed:
ADDRESS Or PROJECT:
Street Address V\ �ec-N`os\i9sm
city Nt- eN\ . -,
Propertyowner }, CT\`X�O_Xl>" Address it DU
Apt. Number �.
Zip CJi\O\nC-1
3o'�h<tx'!.i�tetvac
Telephone Number
Deleading Method: Net/Dry Scraping Heat Gun Liquid Encapsulant
Demolition Caustics LReplacement)
Covering Other
If "Other" selected, please explain
Check one: dwelling is multi-family ✓ single-family
other
Page 2 of 2
Start Date Completion date-1
When will work be done: anEyS,O pmj _t45pecify times on site) Weekends? C■p
Project Supervisor Name e,A..v e-NP\\G Licensel'<X\'3 Exp. Qy
Date`5-a'p-
Workman's Compensation Policy Number\SW-PN-ttSt \1St{-\\ Carrier H ii\\r,s3l&\`m.
In Case of Emergency Contact: contractor's Representative)
1\iS-5W1-''3Cb'6
In accordance with Massachusetts General Laws C. Ill 4197, 454 CUR 22.00 and 105 OM 460.000, notice of the
date end mathod(s) 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 fallowing persons, at least ten
business days prior to the beginning of deteading. NOTIFICATIONS MAY BE FAZED.
1. Department of Labor d Industries, Division of Asbestos and Lead Enforcement
100 Cambridge Street, Roan 1106, Boston, MA 02202 FAX: (617)727-7568
2. Director, Childhood Lead Poisoning Prevention Program oZQS\-'64tp
Department of Public Health, 305 South Street, Jamaica Plain, MA 02130 FAX: (617) 513-4711
(617) 522-8735
3. Occupants of dwelling unit
4. All other occupants of the residential premises, if any
5. local Board of Health/Code Enforcement Agency
6. Massachusetts Historical [omission (If premises are listed on the State Register of Historic
220 Morrissey Blvd. Places, this notification set be made upon receipt of an
Boston, MA 02202 Order To Correct Violation or at least 30 days prior to
FAX: (617)727-5128 initiating preventive deleading)
DELEADING CONTRACTOR:
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, ant 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 No-\■ - 03 1� `\\
Company Name: �Q�l\n i V'FT[C,
Address:
Signed
Telephone Number: 1-\\3 -5a1 -3\\D`e,
NOTIFICATIONS SHALL BE COMPLETED IN THEIR ENTIRETY, DATED AND SIGNED -
INCOMPLETE NOTIFICATIONS WILL NOT BE ACCEPTED AND WILL BE RETURNED BY D.L.I.