Overpass Notification of Deleading 1997 Sulk
ee�lshGa › t.97/D
COMMONWEALTH OF MASSACHUSETTS
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Department of Labor 6 Industries and Department of Public Health
NOTIFICATION OF DELEADING WORK
All sections of this form must be completed in order to comply
with the notification requirements of M.C.L. c.111 5 197,
454 Q 22.00 and 105 CMR 460.000 as most recently amended
FILE MISER: (AGENCY USE)
Contractor performing project Abide, Inc. (Aldo F. Tilli)
License # DC001152
„ Exp.date 10/14/97
Lead Paint Inspector 'Y II /A License #
Date of Inspection
If low-risk deleading work is being performed, complete the following line:
Property owner Agent(s)
Address of Project
Building Name (if any) Floor
Street Address Scum ST Las A`� O` p`f -9t Apt. No.
City freQTH,aM9'rtA% Zip 0/000
Deleading Method: (let/Dry Scrapin>) Heat Gun Caustics
Liquid Encapsulant Covering Demolition Replacement Other
If "Other” selected, please explain
check One:
Start date
dwelling is multi-family single family
10-7497 ism /47 Completion date j.9-4.24- 10 /5A/4%
When will work be done: A.M. kit. P.M. Weekends?
Project Supervisor's name
MitNlr-+ Eokur,An.
Property Owner MA's S 4IC'Y'(NA✓4t �AT
Address
City NciLTN/4n)rr0,4 h State M1
Telephone
In case of emergency contact Frank Tilli
License #
Zip f7/0 t
4t3 52S—tiAt
Phone: day 41-3-24'1 0242 evening 413-525-0644
(over)
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In accordance with Massachusetts General Laws c. III 5 197 CT4R 22.00 and 105 CMR 460.000 notice
of the date and methods(s) of removal or ov e ring of paint, plaster or n
other accessible materials
containing dangerous levels of lead is to be provided and must be received by the following
persons, at least ten (10) days prior to beginning of deleading.
Occupants of the dwelling unit
All other occupants of the residential premises, if any
/019 7_
Director, Childhood Leading Poisoning Prevention Program Fax (617) 751-8436506 9/ ,
p��' I�J/ca/ e,-
Fax (617) 727-7568 '/I`^" /
Department of Public Health, 470 Atlantic Avenue, Boston, MA 02110
Director, Asbestos 6 Lead Program
Department of Labor 6 Industries
Room 11006, 100 Cambridge Street
Boston, MA 02202 "�/y� J� (�� }��
Local Board of Health/code Enforcement Agency 2)0 \ 1 A.l1 f 1 ka )R is ✓�VJ/O fl.T MA.
Massachusetts Historical Commission
220 Morrissey Blvd.
Boston, MA 02125
Deleading Contractor
(If premises is listed on the State Register
of Historic Places, this notification must be
receipt of an Order to Correct
Violations e
olations•o at least 30 days prior to
initiating preventive deleading)
Fax (617) 727-5128
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 and Leading 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 his/her knowledge and belief.
9/2G /91 signed: f//j/.et CC_
Date
Title: President
comps ny: Abide, Inc.
Property Owner (If owner or unlicensed owner's agent will be performing low-risk deleading work)
I certify that I have complied with the training requirements of the
Commonwealth of Massachusetts Lead Poising 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 following low-risk activities (I have circled all that apply) :
applying liquid encapsulant
applying exterior vinyl siding
removing doors, cabinet doors, shutters
I certify that all the information contained in th
best of my knowledge and belief.
Date:
REV 10/12/95
capping baseboards
covering surfaces
otificat ion is flue and correct to the