108 APT#D1 Notification of Deleading 1999 S
department of Public Meal th/Department Of Labor i Industries
Owes
NOTIFICATION OF DELEADING WORE FILE NUMBER
JUNI J99 All sections of this form must be completed in order to comply with
V , the notification requirements of M.G.L.C. 111 4 197,
---- --"- -I 454 CMR 22.00 and 105 CMR 460.000 as most recently amended
AN. HOAFO OF JALTH[I
Contractor performing
project Lte ,t4 License P Exp. Date\-.\ -Q(:).Q`
Lead Paint Inspector License 0-W. a4{
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 I have complied with the training requirements of the Commonwealth of Massachusetts lead
Poisoning Prevention and Control Regulations, 105 CNR 460.175, for owner/agent low-risk abatement and
containment. 1 further certify that I or my agent will be performing the +-following low-risk activities (I
have circled all that apply):
applying liquid encapsulant capping baseboards removing doors, cabinet doors, shutters
applying exterior vinyl siding covering surfaces
I certify that all the information contained in this notification is.true and correct to the best of my
knowledge and belief.
Date: Signed:
ADDRESS OF PROJECT: p pp
Street Address \t % tO 1T'
Apt. Number
City Zip tcn.3
PropertyOwner t 'X f Address a� iSys`\�y∎\\ S &
Telephone Number
Deleading Method: Wet/Dry Scraping Heat Gun
Demolition Caustics
Covering) Other
Liquid Encapsulant
Replacement
If "Other" selected, please explain
Check one:
dwelling is multi-family V single-family
other
Start Date
\a.-aro-'Sq
Page 2 of 2
Completion date\D-3S-W
1'•3G ,. . (Specify When will work be done: am pmm (S
_ times on site) weekends?
Project Supervisor Name tcV\re ,N License# Exp. Date\-\a.-Ol�,
Workman's Compensation Policy Number t1WgPS$an\4
Carr iez�
In Case of Emergency Contact: JC\)\\14. k $$' , (Contractor's Representative)
'A\t-Safi--%\e6
In accordance with Massachusetts General Laws C. Ill 1197, 454 CMR 22.00 and 105 CNR 460.000, notice of the
date and method(s) of removal or covering of paint, plaster or other accessible materials containing
dangerous levels of lead is to be provided and oust be received by the following persons, at least ten
business days prior to the beginning of deleading. NOTIFICATIONS MAY BE FAXED.
1. Department of Labor 6 Industries, Division of Asbestos and Lead Enforcement
100 Cambridge Street, Roam 1106, Boston, MA 02202 FAX: (617)727-7368
2. Director, Childhood teed Poisoning Prevention Program
Department of Public Health, 305 South Street, Jamaica Plain, MA 02130 FAX: (617) 983-6931
(617) 522-8735
3. Occupants of dwelling writ
4. All other occupants of the residential premises, if any
5. Local Board of Health/Code Enforcement Agency
6. Massachusetts Historical Cameission (if premises are listed on the State Register of Historic
220 Morrissey Blvd. Places, this notification oust be made upon receipt of an
Boston, MA 02202 Order To Correct Violations 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 CHB 22.00, anti-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
h iss/her knowledge
and nd belief.
Date \t\■\Q Vi Signed 1e- / / ed)F
Company Name: \ke_VAr. NA\t\tt\ `t .CNalmLcWe\ \1hL
Address: 'CT) C' Stk u ti t\likes ) 'NG t tr ., am\.W
t\tclil
Telephone Number: \3- Jc11- \\04■
NOTIFICATIONS SHALL BE COMPLETED IN THEIR ENTIRETY, DATED AND SIGNED -
INCOMPLETE NOTIFICATIONS WILL NOT BE ACCEPTED AND WILL BE RETURNED BY D.L.S.