41 Deleading Notification 2002 •s e'Lt.
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ABIDE, INC. PROJECT # 0151 '
A
COMMONWEALTH OF MASSACHUSETTS
Department of Labor 2 Industries and Dep tae t f Pub ay. g rs 04
NOTIFICATION OF DELEADING WORK
MI seatinD. of this fors mast be aupl bed it neat to 00 11 I MT w 4 I
vita the nnttficatioa regdite.ata of N.G.L. c.111 5 197 .g t�11
454 CA 22.00 aed 105 OE 460.040 as won r.eently audio.
2112 Basnoinseressepar ISATI
Contactor performing project ABIDE, INC. (Frank Tilli) License # DC00lb19
9/1/03
/ Exp.date Sept ember 1 200;
Lead Paint Inspector - C A R L. C RvLTDI%/ License t
Date of Inspection
If low-risk deleading work is being performed, complete the following line:
Property owner
Address of Project
Building Name (if any)
Street Address 1{ I MAyrvARes Roil-0
Agoutis)
City
neleading method: Wet%Dry Scrapin,
Heat Gun
Liquid Encapsulant Demolition
If 'Other" selected, please explain SolwfwT
C Heise ic4l. t ti4ovell_
Chace Die: d-ellin4 is multi-fanny single family Y
Start date
F�23)02-
Completion date iUJ IS/02-
When will work be done: A.H. 7.00- P.H. 5 :oo Weekends? NO
Project Supervisor's name Robert P. LaMountain License p 053605
Property Owner CNRWSWUPMER. be FRANC,s e 3 FAJNIFfe CRCs
Address 25. 9Ewfy C4.)<1"
City hia&1 jAALP1Dik/ scale MR zip 010(40
Telephone L{ - LLap - %U
In case of emergency contact Frank Ti1Ti , President
Phone: day 413-525-0644 evening 413-525-0644
(over)
100s 003
Aim
Ina cotdance with Massachusetts General Law. c. 111 5 197 Om 22.00 sod 105 O41 460.600 notice
of the date and methods(s) of removal or covering o f paint plaster or other accesslbte materials
csam•ining dangerous levels of lead is to be proviled and must be received by the fallbvinp
persons, at least tee (10) days prior to beginning of deleading.
1. Occupants of the dwelling unit
2. All other occupants of the residential premises, if any
3. Director, Childhood Leading Poisoning Prevention Program
Department of Public Health, no Atlantic Avenue. Boston, 19A 02110
4. Director, Asbestos 6 Lead Program
Department of Labor < Industries
Room 110D6, 100 Cambridge Street
Boston, MA 02202
5. Local Board of Realth/eoge Enforcement Agency(^IO( 'Mao(r'""
6. Massachusetts Historical Cownis,iun
220 Morrissey Bbd.
Boston, MA 02125
Deleading coetraetor
•
Fax (G17) 284-84/0
Ear (6171 721-7560
Frek6(3)n7" 1"I
lir premises is listed on the State Register
of Historic Places, this notification coot be
vleau%ns recGiltlofsanl0 days to Correct
ys prior to
initiating preventive deleedinol
Fax 1617) 727-5)20
The undersigned hereby states, under the pains and penalties of perjury, that
be/she has read and understood the Commonwealth of Massachusetts Deleading
Regulations, 454 CMR 22.00 and Leading Poisoning Prevention and Control
Regulations, 105 CM 460.000, and that the information contained in this
notification is true and correct to the best of his/her knowledge and belief.
C /0% Signed: :S Date fnAJr-
lli
Frank Ti
r2.cee President,
company: ABIDE. INC.
Property Owner (If owner or unlicensed owner's agent will be performing low-risk deleading work)
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 encapaulant
applying exterior vinyl siding
removing doors, cabinet doors, Shutters
capping baseboards
covering surfaces
I certify that all the information contained in this notification is true and correct tv, the
best of my knowledge and belief.
Date: signet: __
ABIDE, INC. PROJECT # 02.57C:(
REV 10/12/95