212-214 Notification of Deleading 1998 n
X
DEPARTYCNT OF FUBBLIC REAL^.!1/DEFARTMENT OF LABOR d
NOTIFICATION OF DELEA DI NC WORK
Lead Paint Inspector
Contractor perfoming
Address of Project
•.:-c ^ue ' ter:e :! t crier t.
FILE NUMBER
Date of Inspection
a(Ut 1.D
pro ec -11u7r ��_ License N CplOy$'
Building Name (if any) r.(\(2, cmc-N, ,) , y Q P .PC -C
Street Address 2x2-21L r % ,
� NJ�L'Ci-i i�A•�lc Apt. No.
NJ'. . Zip
Ci ty
Deleading Method: DRY SCPINC HEAT CUM ENCAPSULATION DEMOLITION
POWER SANDING CAUS('ICS REPLACEMENT OTHER
"Other" selected, please explain
(circle all that apply)
Cheok ore: dwelling is Multi-family single family ✓
Start date /%�/09
When will work
Completion Date 0/21-(/-5g
be done: am t✓ pm ✓ weekends?
Project Supervisor Name (l1;C.a0, _L (\n0 '1 r-
Property Owner .
License N Ct 3-i cLI
Address_ PVT
City 2-w-1cxc
Telephone trite �L-t'Z 74-c ^�M
In case of emergency, contact what person:(`('\cood(EL ifto2C -
Phone: Area code required day (2c-» j"9-p,¢ : , evening iF 2 (yOZ24oSZa
State ! ,AR Zip en-1- \ 0
(OVER,
rev :2/0;/90
J . .
In necordarce with 7hseter 773 of the Acts of 1957, Maasechueefis ;,.newel Lows
C. 111 5197, 454 CMR 22.00 and 105 PMR 460.000, notice of the date and methad(o) of
removal or covering of paint, plaster soil or other accessible catern: containing
dangerous levels of lead, is to be provided to the following persons at least five
days prior to the beginning of deleading.
2. All other occupants of the residential promisee, if any
3. Director, Childhood Lead Poisoning Prevention Program
Department of Public Health, 305 South Street, Jamaica Plain, MA 02130
4. Lead Removal Program, Bureau of Technical Services
Department of Labor and Industries, Division of Industrial Safety
100 Cambridge Street, Room 1101, Boston, MA 02202
5. Local Board of Health/Code Enforcement Agency
6. Massachusetts Historical Commission
(if premises is listed on the State Register of Historic Places)
The undersigned hereby states, under the penalties of perjury, that s/he has read
and understood the Commonwealth of Massachusetts Deleading Regulations, 454 CMR
22.00, and Lead Poisoning Prevention and Control Regulations, 105 CMR 460.00, and
that the in•ormation contained in this notification is true and correct to the best
of .his/her knowledge and belief.
Date
Signed:
Title:
Company: 1 L-ptsr QC NT7A-no,,,
Address:?D _ L r1 olio(
Telephone 0: � - Jn oC'SS'
Office Use Only
0012116
rev 12/05/90