269 APT#2A Notification of Deleading 1996 In accordance with Massachle _ts General Laws c. 111 4 197 04R 22.000 Nd 105 CR3 460.000 notice
of the date and methods(s) removal or covering of paint, plaster other accessible materials
containing dangerous levels of lead is to be provided and must be received by the following
persb4l t I2�st ten (10) days prior to beginning of deleading.
1. + ,
1. Occupants of the dwelling unit
2. All other occupants of the residential premises, if any
3. Director, Childhood Leading Poisoning Prevention Program Fax (617) 753-8436
Department of Public Health, 470 Atlantic Avenue, Boston, MA 02110
4. Director, Asbestos S Lead Program Fax 16171 727-7568
Department of Labor d Industries
Room 11006, 100 Cambridge Street
Boston, MA 02202
5. Local Board of Health/code Enforcement Agency
6. 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
made upon receipt of an Order to Correct
initiating preventive deleading)
Fax (617) 127-5128
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.
Date 3//O / Ill4 Signed: //SW -7 /tei V(rno'yyle,—
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 doors, cabinet doors, shutters
capping baseboards
covering surfaces
I certify that all M= information contained in this notification is true and correct to the
best of my knowledge and nel ief.
Date: Signed
REV 10/12/95
CS4ONWEALTH OF MASSACHU__,TTS
Department of Labor S Industries and Department o
NOTIFICATION OF DELEADING WORK
All sections of this form must be completed in order to
with the notification requirements of M.G.L. c.111 S 7
454 CNA 22.00 and 105 Ca 460.000 as most recently - n.
NOPTHAMPTON BOARD CF
FILE NUMBER: (AGENCY USE)
NPR 2 1 1996
Contractor performing project THOMAS E. PALMER
# DC 001077
license
Exp.date 04-02-96
Lead Paint Inspector PETER MILLER License ♦ T 2ROR
Date of Inspection01 -09-96
If low-risk deleading work is being performed, complete the following line:
Property owner Agent(s)
Address of Project
Building Name (if any) Floor
269 MAIN STREET N 2A
Street Address Apt. o.
City NORTHAMPTON, MA Zip 01060
Deleading Method: Wet/617V-§-EFT:30. Heat Gun Caustics
Liquid Encapsulant overing Demolition Qeplacement) Other
If "Other" selected, please explain
Check One: dwelling is multi-family XX single family
Start date APRIL j3 1996 Completion date APRIL 212/ 1996
When will work be done: A.M. XX P.M. XX Weekends? YES
Project Supervisor's name
N/A License #
Property Owner FRANCIS A. JOHNSON
Address 275 MAIN STREET
City NORTHAMPTON State MA Zip 01060
Telephone 413-584-9005
In case of emergency contact
Phone:
day 413-731-6666
WILLIE MAE ARCHIBONG
evening
(over)
413-736-3287