92 Notification of Deleading 2000 p1
Department of Public Health - Childhood Lead Poisonin Prevention Program
'wner/Agent Deleading Notificnan
Please complete all sections of this form clearly. Incomplete or illegible forms will be returned.
Lead Paint Inspector Join
Set
License 41- 11 92.
Property Owner VAV Id ektiai'1 • 4Y1 Zimmer
Property Owner's Address 2442 5tet-tc_ St.,
Nort�,n,rrIp cn MA 6inDmt3
Authorized person performing work: Dad lA A1K.4n Lic#/Auth.# Ob ioe5O— CY\
Address of authorized person 2.4.6 54-0.1-e Si' . flcr Ala n p. oY11 M A Zip Code OIOk 3
Telephone Number(4I2) 584-47o9
Address where the work will be done:
Building Name(if any) Floor CL1
Street A.dress nt:4 rd Rd. Apt No.
City Zip Code O t O to The property is a_multi-family f single family.
Inspection Date 3'17'60
Zip Code 010L0
Deleading Method(s):
❑ Making paint intact(high ❑ Dippin
risk) O
❑ Demolition
❑ Scra in • maid encapsulant'�
�7 omponen • ovenng
removal/re lace t ❑ Capping baseboards /
The work will begin on`, ,2C1&and will finish by+/11/eriThe work be done in the "/ am 'Jpm or �/ weekends.
In Case of Emergency Contact Ve0,n 7 rrmC r (Pttk)
Daytime Phone (24.13) 5R'1 -4109 Evening Phone ?a me
[le Property Owner must complete and sign the following information:
certify that only authorized persons who have complied with the training requirements of the Massachusetts Lead Poisoning
'revention and Control Regulations, 105 CMR 460.000,will conduct deleading work. I further certify that the authorized
ierson(s)will not exceed the scope of his/her authority and will be performing only those activities circled above. All of the
aformation contained in this document is true and correct to the best of knowledge and belief.
Date 7 hobo Signed et didtrIl,i
❑ Applying vinyl siding on
exterior
sf Component removal (low
sk common
❑ Other:
The following people/agencies most be notified ten days before beginning work: *
I. Occupants of the dwelling unit
2. All other occupants of the residential premises, if any
3. Childhood Lead Poisoning Prevention Program,DPH
56 Roland St., Boston,MA 02129-1235
4.Asbestos and Lead Program, DLWD
399 Washington St.,Boston,MA 02108
6. Local Board of Health/Code Enforcement Agency
'St.-?-12.Itt
L
1 C NISI
,XA,, tO O
T
NORTHAMPTON BOARD OF HEALTH
Fax(617)284-8436
Fax (617) 727-7568
10 fek wn 51-, tarn I
' If the home is on the State Register of Historic Places,call the MA.Historical Commissio at(617)727-8470.
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