269 APT#3B Notification of Deleading 1996 In accordance with Massacr its General Laws c. 111 4 197 CMR 22.00",e1d 105 CMR 460.000 notice
of the date and methods(s) removal or covering of paint, plaster other accessible materials
containing dangerous levels of d is to be provided and must be received by the following
persons, at least ten (10) days prior to beginning of deleading.
1. Occupants of the dwelling unit
All other occupants of the residential premises, if any
Director, Childhood Leading Poisoning Prevention Program Fax (617) 753-8436
Department of Public Health, 470 Atlantic Avenue, Boston, MA 02110
4. Director, Asbestos c Lead Program
Department of Labor 6 Industries
Room 11006, 100 Cambridge Street
Boston, MA 02202
Local Board of Health/Code Enforcement Agency
Massachusetts Historical Commission
220 Morrissey Blvd.
Boston, MA 02125
Deleading Contractor
Fax (617) 727-7568
(If premises is listed on the State Register
of Historic Places, this notification must be
made upon receipt of an Order to Correct
Viola:inns or at least 30 days prior to
initiating preventive deleadinyl
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 t7ue and correct to the best of his/her Ytxtpyk)edge and belief.
i
Date % /
5(5 ✓/ //
signed: /446x1✓/ -I
title: DELEADING CONTRACTOR/OWNER OF
company:RemlaP LEAD PAINT REMOVAL CO. , 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 donts, cabinet doors, shutters
capping baseboards
covering surfaces
I certify that all the information contained in this notification is true and con ect t,, thr
best of my toil edge and hell eI.
Gate: Signed:
REV 10/12/95
ismiN
C .4MONWEALTH OF MASSACHUL.ITS
Department of Labor G Industries and Department of Publ
NOTIFICATION OF DELEADING WORK
0
1th
MAY 311996
All sections of this form must be completed in order to comp
with the notification requirements of M.G.L. 0.111 4 197, NORTHAMPTON BOARD OF HEALTH
454 QIR 22.00 and 105 OMR 460.000 as most recently amended
FILE NUMBER: (AGENCY USE
Contractor performing prged THOMAS E. PALMER license # DC 001077
Lead Paint Inspector
FOLEY
Exp.date 04-1 5=97
License #I 1208
Date of Inspection o1 _9n_g6
If low-risk deleading work is being performed, complete the following line:
Property owner
Address of Project
Building Name (if any)
Street Address 269 MAIN STREET
Agent(s)
Floor
Apt. No. 3B
City NORTHAMPTON. MA Zip 01060
Deleading Method: Wett y Scraping Heat Gun Caustics
Liquid Encapsulant COovering ) Demolition ep1 cement Other
If "Other" selected, please explain
Check One:
dwelling is multi-family
XX
single family
Start date 06-14-96 Completion date 06 25 9G
When will work be done: A.M. XX P.M. XX Weekends? YES
Project Supervisor's name N/A License it
Property Owner FRANCIS JOHNSON
Address 275 MATN STRFFT
City NORTHAMPTON, State MA
Telephone 413-584-9005
WILLIE MAE ARCHIBONG
Zip ()loco
In case of emergency contact
Phone: day 413-731-6666
evening
(over)
413-736-3287