23 Notification of Deleading 1991 ," -
In accordance with Chepter 777 of the Acts of 1987, Massachusetts General Laws
C. 111 5197, 454 CMR 22.00 and 105 CMR 460.000, notice of the date and method(s)
removal or covering of paint, plaster soil or other accessible material containinc
dangerous levels of lead, is to be provided to the following persons at least fiv:
days prior to the beginning pE deleading.
1. Occupants of the dwelling unit
2. All other occupants of the residential premises, if any
3. Director, Childhood Lead Poisoning Prevention Program
Department of Public Health, 305 South Street, Jamaica Plain, MA 02130
4. Lead Removal Program, Bureau of Technical Services
Department of Labor and Industries, Division of Industrial Safety
100 Cambridge Street, Room 1101, Boston, MA 02202
5. Local Board of Health/Code Enforcement Agency
6. Massachusetts Historical Commission
(if premises is listed on the State Register of Historic Places)
The undersigned hereby states, under the penalties of perjury, that s/he has reed
and understood the Commonwealth of Massachusetts Deleading Regulations, 454 CMR
22.00, and Lead Poisoning Prevention and Control Regulations, 105 CMR 460.00, and
that the information contained in this notification is true and correct to the best
of his/her knowledge and belief.
Date 9/4/91
Signed: ezµ` f� ,�-
Title: Deleader Contractor
Company: Affordable Contracting
Office Use Only
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r� Al1/4
DEPARTMENT OF PUBLIC HEALTH/DEPARTMENT OF LABOR 6 INDUSTRIES
NOTIFICATION OF DELEADING WORK
All sections of this form must be completed in order to comply with
the notification requirements of M.G.L. C. 111 5197
FILE NUMBER
Lead Paint Inspector Walter C . Dembeck
Date of Inspection 8/14/91
Contractor performing project Affordable Contracting
Address of Project
Building Name (if any)
Street Address 23 Marshall St.
License # DC 000613
Floor
City Northampton, MA:
Deleading Method:
(circle all that apply)
Zip 01060
Apt. No.
DRY SCRAPING CHEAT GUN) CENCAPSULATION) DEMOLITION
POWER SANDING
If "Other" selected, please explain
CAUSTICS CREPLACEMENT) OTHER
Check one: dwelling is Multi-family single family X
Start date 9/10/91 Completion Date 9/14/91
When will work be done: am X pm weekends?
' Project Supervisor Name Edward E. Truehart License # DC 000613
Property Owner Rene D. Joly
Address 215 North St .
City Northampton
State MA Zip 01060
Telephone (413) 584-9530
In case of emergency, contact what person: Anne Newton
Phone: Area code required day (508) 249-6332 evening same
(OVER)
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rev 11/16/89