269 APT#3A Notification of Deleading 1996 In accordance with Massaclaffts General Laws c. 111 4 197 CMR 22.040lnd 105 CMR 460.000 notice
of the date and methods(s. r covering or c ing of paint, plaster 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.
1. Occupants of the dwelling unit
2. All otker 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
Director, Asbestos s Lead Program
Department of Labor a Industries
Room 11006, 100 Cambridge Street
Boston, MA 02202
5. 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
Violations at least 30 days prior to
initiating preventive deleading)
Fax (6171 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 q'rue and correct to the best of his/her knot2Sledge and belief.
Date
Signed:
%2Dro.-ii7 /lc
Title:
OWL
DELEADING CONTRACTOR/OWNER OF
company:RemlaP LEAD PAINT REMOVAL CO. , INC.
Property Owner Of 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
capping baseboards
covering surfaces
I certify that all rh* information contained in this notification is true and correct to th
best of my knowledue and belief.
Date:
REV 10/12/9k
C.,tONWEALTH OF MASSACHUL..TTS
Department of Labor a Industries and Department of
NOTIFICATION OF DELEADING WORE
All sections of this form most be completed in order to
with the notification requirements of N.G.L. 0.111 S 1
454 Qet 22.00 and 105 QOi 460.000 as most recently a
FILE NUMBER:
Contractor performing project THOMAS E. PALMER
Lead Paint Inspector TIMOTHY FOLEY
License # DC 001077
Exp.date04-15-97
License IT 1208
Dste ..f *napertinn 01_1Q=96
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
269 MAIN STREET
City NORTHAMPTON, MA
Deleading Method:
Liquid Encapsulant
Apt. No.
zp
Zip ninon
Wet/pry Scraping Heat Gun Caustics
Demolition eplacement Other
If "Other" selected, please explain
Check One:
dwelling is multi-family XX
single family
Start date 05-11 -96 Completion date 05-20-96
When will work be done: A.M. XX P.M. XX Werkends? YRS
Project Supervisor's name N/A License 4
Property Owner FRANCIS JOHNSON
Address 275 MAIN STREET
City mnomwsMPTONp State MA Zip nln6n
Telephone 413-584-9005
In case of emergency contact
Phone: day 413-731-6666
WILLIE MAE ARCHIBONG
evening
(over)
413-736-3287