20A Notification of Deleading 1999 Department of Public Health - Childhood Lead Poisonyjin,g Prev
en Owner/Agent Deleading Notir'-'atiion
Please complete all sections of this form.
Lead Paint Inspector ,Ti9,,f•kj ��9-ent4yN/
Property Owner I..l t L L t/ 1=ad y f.e
Address /,S72/tncorvf- View ise,
Agent(if applicable)
Address
License 4 fi ry-s/
enttbl 731,Air.q °
it
JUN 2 219A7
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Address where the work will be done:
Building Name(if any)
Street Address 40h- �t� t5-rAa„/.-
City Zip Code d(0(e 0
Deleading Method(s): Liquid encapsulant
Applying Vinyl siding on exterior placement of doors binet doors, and shutters
The work will begin on 1/ f/2nd will finish by J/o2ff ff The work be done in the am Lc pm or Xweekends.
In Case of Emergency Contact lie it reed Pot f t°
Daytime Phone //a ?y7 9g - EveningPhone v/? -5$y Vora )42/ 73 •
The Property Owner must complete and sign the following information:
I certify that I have complied with the training requirements of the Commonwealth of Massachusetts Lead Poisoning
Prevention and Control Regulations, 105 CMR 460.000,for owner/agent deleading. I further certify that I or my agent
will be performing only those activities circled above. All of the information contained in this document is true and
correct to the best of my knowledge and belief
Date W(%� Signed Cs ,�,`
The following people/agencies must be notified ten days before beginn ng work "
I. Occupants of the dwelling unit
2. All other occupants of the residential premises, if any
3. Childhood Lead Poisoning Prevention Program,DPH
470 Atlantic Ave, Second Floor, Boston,MA 02210
4. Asbestos and Lead Program, DLWD
Room 1106, 100 Cambridge Street, Boston, MA 02202
5. Local Board of Health/Code Enforcement Agency
"If the home is on the State Register of Historic Places,notification requirements may vary. Call the MA. Historical
Commission at(617) 727-8470.
Floor 9 4/d
Apt No.
The property is a X multi-family single family.
2Few.tr
r
Wire Mr.William Boyle
15 Pl easantvw Dr.
Hatfield,MA 01038-9725
Fax(617)753-8436
Fax(617) 727-7568