108 APT#A10 Notification of Deleading 1999 JUN 15 1999
a
Department of Public wealth/Department Of Labor 8 Industries
NOTIFICATION OF DELEADING WORE FILE NUMBER
ALl sections of this form must be completed in order to comply with
the notification requirements of M.G.L.C. 111 § 197,
454 CMR 22.00 and 105 CMR 460.000 as most recently amended
ConLraotea---performing project t p. e- ' iLicense 0 Exp. DateN0 -tQ
Lead Paint Inspector
-f-sn'tte, et License # " M Lk
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
1 certify that 1 have complied with the training requirements of the Commonwealth of Massachusetts Lead
Poisoning 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 4-following low-risk activities (1
have circled all that apply):
applying liquid encapsulant capping baseboards removing doors, cabinet doors, shutters
applying exterior vinyl siding covering surfaces
1 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�� `\ ,
Street Address \V::::&`) i^L.Vrtl•■
Apt. Number Y\Ar.)
City Nrc4E4ort. Zip o\fl\nt
PropertyOwnerR� Nfl\�a�.t_, Address a t�Lxa�L� `��R�
N tp ZrA
Telephone Number
Deleading Method: Wet/Dry Scraping Heat Gun
Demolition Caustics
(:Covering) Other
If "Other" selected, please explain
Liquid Encapsulant
Replacement
Check one: dwelling is multi-family 'V single-family
other
Page 2 of 2
Start Date �Lt-a.�"(V\
Completion date\O-ate-Sq
1'•3G , _ (Specify When will work he done: am pmm_ (specify times on site) Weekends?
Project Supervisor Name t%4\tie X•444241, License# Exp. Date\-\a-Ot.
Workman's Compensation Policy Number cei$a�A
Carrier` \
In Case of Emergency Contact: (Contractor's Representative)
'AV -5 1-7LN\Ot.
In accordance with Massachusetts General Laws C. 111 1197, 454 CMR 22.00 and 105 CMR 460.000, notice of the
date and method(U 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, Row 1106, Boston, MA 02202 FAX: (617)727-7568
2. Director, Childhood Lead Poisoning Prevention Program
Department of Public Health, 305 south Street, Jamaica Plain, MA 02130 FAX:6(617)22 3- 31
69
3. Occupants of dwelling unit
4. All other occupants of the residential
5. Local Board of Health/Code Enforcement
6. Massachusetts Historical Cc:mission
220 Morrissey Blvd.
Boston, MA 02202
FAX: (617)727-5128
premises, if any
Agency
Of praises are listed on the State Register of Historic
Places, this notification mot be made upon receipt of an
Order To Correct Violations or at least 30 days prior to
initiating preventive deluding)
DELEADINO 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, ant lead Poisoning Prevention and Control
Regulations, 105 CHR 460.000, and that the information contained in this
notification is true and correct to the best of nhis/her knowledge and belief.
Date t *ib.. \Lk \tk k (\\_ /� Signed J ( P- ` /(n
Company N11ame: `\fVvr C is `T`�T `
Address:
mib
aps 'WNW NIL
Wh 7S-X-4-
Telephone Number: 1-\\-?1- 31- .\\01IN
• \ s txt ai
NOTIFICATIONS SHALL BE COMPLETED IN THEIR ENTIRETY, DATED AND SIGNED -
INCOMPLETE NOTIFICATIONS WILL NOT BE ACCEPTED AND WILL BE RETURNED BY D.L.I.