108 Notification of Deleading 1998 ALL
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Deparmmnt of PLalle Meal:h/
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NOTIFICATION OF DFi.6'ADING WORK ISdING4AMMONBOARDOFHEALTM
ons of this form nu t be cceeitled in f t0 ccApl wlth
an[ 9 M 1 C. i 197,
4 CAR 27.00 end 1 C ..: .,_C a. bast recently a_ende
Co tractor perform!ng projeccA ebi [I C. 1'e.rto
Lead Paint 1nsgector Anse Crochivrc
Licens
License x
L' '0J14 )
0. Da`_o+ '
?&^PEPPY OWNIR (If owner or unlicensed owner's agent will be Nettie_
n.lt
r_sk -ere__ work,
comple e the following ) ;
Property Owner Age nt!sl
Addr La
Telephc ne Number
! certify that 1 have cospl
Pasoninc Prevention and Co
coptaiiner. f her Cef
Ie C Reid i
the training requirements of the Cortmonweait of Massachusetts Lead
g t Nj5 CMm 460.175, tor- cuneriatenc w-ri [ ee..teitent air!
- aln Y acerb wi(i oe perfcrming the I_p hir tot.hrisk art'.v'aes (_
a,pLying Liquid encap,u.znt capping beset-cods rerovIng doors, cab'.net doors 'hbtters
'Y!ng exterior vtnyt vain!, 'a�--- t2:%\
I Certify that a t the infor i nut f'
kno _ ,_q y - con Le °- ,' 'n. co v ect to he hest of rY
Date: 7-23-(M signed: qy-{
AnnaE.55 OF PROJECT:
Street Address LUu SeeN Street
Nor Lhempton, MA
Propertyowner ocit4
Address
Telephone Number 41 3-585-2252
Deleading Method: Wet/Dry Scraping Heat Gur
Gemolition Caust Ics
�COVe%ti8!7 Other
rt "On h^r" selected, please explain___
Aot. Nu
0106;1
bP_t
Liquid 4:.caoeul_ant
noplacetthat
'heck one:
c!wellino is multi-family__* single-family
Start _o . _
c en will work he done: at9
rvi
norkman'a Compensation Policy Nup,ber
ISreci
__ce
76075',91—C
p
Carr;er ' /..
In Case of ° ..ergency Contac`: .l t,v'1 LJ 11. \''1- '°
i
---- !contractor's Represent ar' oo;
th Ms 1
dote nd ( J of '- - J r, S _ 2.' 105 ate 460.000,
SL 9 co, notice of t
o roe t P -e
R
V f to r d and ote m l to -
s.ces,: days or took bon on:1H,of by the 1 t Inc
,J. 1..T_, a.,l'1 fS 141.'t !R 9:PI'jtY_'2i.
1.
2. 9 [ t-
of Labor & industries, Division of
as nd : h
itl o e7ent C h doe Street, Roa- - (6'7)./27 7:60
p
Oenat e 1 le od Lead Poisoning Pre(tni ion Pro J a
.On, of P b -c boeth
scree[ Jamaica Plain, NA 0230 FA%e L}
x ( ]) 9-27.11 1
Occupants of tlue{Ling unit ! 52"'-+7.
4. All other occupants cf the rteu.. .. prat acs, if
day
Local p.onrd of neatth/Code enfortunec- spa icy
Massachbhetts bistorical
r
csi 220 v y if e a the State Register of �lorie
122C2 (toff teto at
be Upon rec l
r.
(617:727-b 229 or or To -
C t Violations an at leact tidid says or
v..a.__g preventive dolea ins) to
n`-'_ fOr\G_rc
The undersigned
hereby states,
n e the pains and ac hus of perjury,_
that
Aet he/she has and u: d c d once eiIt h of Massachusetts penalties
r'eo nc e Matto s, 454 C R 74 L a Poisoning Prevent L cn and edn tn0:Neo ae�on '05 440.400, and the information contained in this.ot icnt on is true and correct o th e best of his/he r knowledce
and bet
Date July 23, 1994 j isf.
signed S
Kevin C. Norm Construction, l
Company Name:
Address: ')0 Southampton '.toad, her.dly fpco
Telephone Number: 413-527-2163
01027
NOTIFICATIONS SHALL BE COMPLETED TN.EIR ENTIRETY, DATED AND SICNCD _
I :co.4pLETE NOTIFICATIONS WILL NCI _
ACCEPTED ti;D WI'r BC CdE=};ED AY D.L.T.