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220 Notification of Deleading 1999 w Come ESy NUT1F"\ CAaV\oN -*- COMMONWEALTH OF MASSACHUSETTS Department of Labor t Industries and Department of Public Hdalth NOTIFICATION OF DELEADING WORK AUG 3 1999 All sections of this form must be completed in order to comply with the notification requirements of M.G.L. c.111 S 197, 454 CUR 22.00 and 105 Q9i 460.000 as most recently amended _ ✓'TOY COA(D JFHEALTH- . -. .FINE Imlfl3tSL — (AGENCY USE) ..� Contractor performing project Lead Paint Inspector AR�1D F : _ iNc. License# ,1C I C I 'j Exp.date Vi3t/o1 License # Date of Inspection If low-risk deleading work is being performed, complete the following line: Property owner Agent(s) Address of Project Building Name (if any) UAJ 1TAM1 AAi CHURCH Street Address 'as0 Mme,^ J?Q t City / V \. 11-_ _ ._l nAY/fl Deleading Method: '�Wet/DryfScraping Heat Gun Liquid Encapsulant Covering Demolition Replacement Other If "Other" selected, please explain Floor Apt. No. Zip C5lOro© Check One: dwelling is multi-family single/family Cerv, g[staEoi3 Start date fk yra. a /jq9 Completion date u34- I? Jcn7 When will work be done: c 5 ;W —0 5 : uo Weekends? Project Supervisor's name Q 2{ e 1 - AQAI1Aa T� � 1- ` i(�License if �-43� Property Owner �'\R, Uc\ .\- c-\1 (\ Sn[~a'e Address aao AA4x t1 S i 44 City /1Jnckba .. .. t7 - State ,t4 A- Zip p10Co_C3 Telephone r.j('ll-gill _ `SAO In case of emergency contact \ AA. ( 0_4_1 Phone: day y«- Say- 0G 99 evening (over) ht-)3- nas- o6ivy Ar , [r,c . Ps-osec-F # 99a 15 Zn accordance with Massachusetts General Laws c. 111 i 197 CeS L.2.00 105 cm :60.000 notice of the date and methods(sl of removal or covering of pain:, ? other accessible materials containing dangerous levels of lead is tocbeeprovided and ansnebe received c, the following persons, at least ten (10) days nrior to beginning of leleadinc. 1. Occupants of the dwelling unit 2. All other occupants of the residential premises) - any 3. Director, Childhood Leading Poisoning Prevention ention 2-::c ram Department of Public Health, 470 AtlanticAvenue, Somme • 4. Director, Asbestos s Lead Program Department of Labor 5 industries Room 11006, 100 Cambridge Street Boston, MA 02202 5. Local Board of Health/Code Enforcement Agency 6, Massachusetts Historical Commission 220 Morrissey Blvd. Boston, MA 02125 Deleading Contractor J_.- Fax .a J. --436 Fax .51 727-7565 (ff premiss is the Stare Register of Historic Places, this notification -lust be receipt of an Order to Correct Violations or at least 3O days prior to ..... > preventive•.a Fax 727-3139 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 Signed: Title: {ORES\DENT Company: AS "Inc Wilk Property Owner (If owner or unlicensed owner's agent will be performing low-risk deleading wort) N4 R 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, shutters capping baseboards covering surfaces I certify that all the information contained in this notification is true and correct. t' th best of my knowledge and belief. Date: Signed: ccxxt F Sy No7 \F\ CA-z\ ON REV 10/12/95 Ab;ae 1Z(1C • Pcvsec- - '44 ' 9a 15 Co�'ti ESy NOT\F\C'"1 V\oN -*- COMMONWEALTH OF MASSACHUSETTS r Department of Labor t Industries and Department of PublIO! 14 Bead - �i NOTIFICATION OF DELEADING WORK JUL 22 199910 All sections f this form must be completed in order to comply with the notification requirements of M.G.L. c.111 S 197, 454 CHR 22.00 and 105 EMa 460.000 as most recently amended ' ,',;,-1, FTOiN BOARD OF HEALTH - . FILE NUMBER: (AGENCY USE) Contractor performing project A '0C j Z nC. Lead Paint Inspector NSA License # .DC C Ci I c “ 1 Exp.date .713)hi License # Date of Inspection �^ if low-risk deleading work is being performed, complete the following line: Property owner Agent(s) Address of Project Building Name (if any) UA kliNfa hA/ CHu¢cFj Floor Street Address aq('> M0.;^ 3. Apt. No. City n f-U-4/ <kenekOYI Zip CAUCoQ Deleading Method: Wet/Dry Scraping Heat Gun (Caustics) Liquid Encapsulant Covering Demolition Replacement Other If "Other" selected, please explain AlOcheck One: dwelling is multi-family single family Start date Q.iw f� When will work be doned`o'ne::: 199`1 Completion date 1'.uO --0 5 : W )V54 fl 1997 Weekends? Project Supervisor's name 1cZ( (Z-} P. j G )4144464License O Du3Q5 -Ting._ Lin; 3r-oc\ &fl S1oc t Address 'a.7.o /tA1%j i\ 5 tk City C)(4nrA � ,/1 State A A- Zip o ' oCoCTh Telephone ("j- S$y ' \✓ to Property Owner In case of emergency contact FRANY� T tLLI Phone: day yi 2N— sDs- OG 7 / evening (over) 9121- ASae , me . &4 ec.-4 0- qqa �S �* S accordance with Massachusetts General Laws ill 5 :11 - .00 and - ^'iR 450.300 notice of the date and mechcdstsl of removal or ov ring of saint, - r accessible materials piaster dleastote levels of lead tr±or oobeg nnInprovided ] aO:n be received following must persons, at least ten (101 dews a_o_ to beginning of _.'-ad_.-.ce 1. Occupants of the dwelling unit 2. All other occupants of the resident iai premises _f 3. Director, Childhood Leading Poisoning v Prevention- ? Health, Department of __n___ Health, -0AtlanticAvenue, -o- Director, Asbestos s Lead Program Department of Labor : industries Room n,0A, 220 Canb c dce Street Boston, MA 02202 5. Local Board of Health/code Enforcement Agency 6. Massachusetts Historical commission 220 Morrissey' Blvd. Boston, MA 02125 Lax .a_. -143e 01.f 'remises La _ o the Stnce Historic of receipt _n Order mace doom r_-_a___ns or at lass: 30 days prier to Fax ,n_. _ .r-y 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 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 -7Iaol95 Signed Title: eRss mN A 1 Company: E},h‘de 1(-1c /�-t�Property Owner (If owner or unlicensed owner's agent will be performing low-fish deiea (I R 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, shutters capping baseboards covering surfaces I certify that all the intormation contained in this notification is true and correct the best of my knowledge and belief. Date: REV 10/12/95 Signed: CCX-K■ \ F Sy Nom \F\ CA-VI oN Ak;ae 1-- nc. • Pros€cF