67 Notification of Deleading 1996 In accordance with MassacF, :ts General Laws c. 111 4 197 04R 22.0r1d 105 CMR 460.000 notice
of the date and melbuds(s) _ r emoval or covering overing of paint, plaster other accessible materials
containing dangerous levels of lead is to provided and must be received by the following
persons, at least ten (10) days prior to Hoeginni.ng of deleading.
1. Occupants of the dwelling unit
All other occupants of the residential premises, if any
Director, Childhood Leading Poisoning Prevention Program Fax (611) 753-8436
Department of Public Health, 470 Atlantic Avenue, Boston, MA 02110
4. Director, Asbestos 6 Lead Program
Department of Labor 6 Industries
Room 11006, 100 Cambridge Street
Boston, MA 02202
Local Board of Health/Code Enforcement Agency
Massachusetts Historical Comm)
220 Morrissey Blvd.
Boston, HM 02125
Deleading Contractor
Fax (617) 72/-0568
(If premises is listed on the State Register
of Historic Places, this notification must be
made upon receipt of an Order to Correct
Violations or at least 30 days prior to
initiating preventive deleading)
Fax (6171 727-512G
The undersigned hereby states, under the pains and penalties of perjury, that
he/she has read and understood the Coltmtouwealth 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.
bate manly 11 , 1994
Sign
Tit le: President
companvAccuTech maul ation&.. rnntracting, Inc.
Property Owner If owner or unlicensed owner's agent will be performing low-risk deleadiny work)
I certify that I have complied with the training requirements of the
Commonwealth of Massachusetts Lead Poising Prevention and Control Regulations,
105 CMR 960.175, 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 en.apsaant
applying exterior vinyl siding
removing doors, cabinet dm,a 9, shwttets
capping hasenuamis
covering sotfaces
1 certify that an the info' gat b. ,.,ntalned in into not l fimatiun IS tine and correct to urn,
beet of my knowledge and belief).
REV 10/12/05
Oa 01
COMMONWEALTH OF MASSACHUS.LTTS
Department of Labor 6 Industries and Department of Pub
NOTIFICATION OF DELEADING WORK Ilu-nu(I X996 .� t
All sections of thin form must be completed in order to corn ly
with the notification requirements of M.G.L. c.111 S 197
454 0411 22.00 and 105 DNR 460.000 as most recently amends NORTHAMPTON BOARD OF HEALTH
FILE NUMBER: (AGENCY USE)
Contractor pedonning projectArruTerh Tncnlatinn &
Contracting, Inc.
Lead Paint Inspector Walter Denbek
License # DC-000660
Exp.date 5/13/97
License # 11155
Date of Inspection 3/29/96
If low-risk deleading work is being performed, complete the following line:
Property owner Florence Savings Bank
Address of Project
Building Name (if any)
Street Address 67 Main Street
Agent(s)North River Real Mutate
Management
City Florence
Deleading Method: Wet/Dry Scraping
Meat Gun
Floor
Apt. No.
Zip nino
Caustics
Liquid Encapsulant Covering Demolition ®- Other
If "Other" selected, please explain
check One: dwelling is multi-family X
Start date 7/29/96
single family
Completion date
When will work be done: A.M. 7:00 P.M3 •30
Project Supervisor's
Property Owner
Address Main Street
City Florence
Telephone 586-1300
name Felix Rivera Jr.
8/9/96
Weekends? No
License II DS2026
r . .. r .
State
MA
In case of emergency contact John F Riordan
Zip nin60
Phone: day 592-5326 evening 736-6934
)over)