8 Deleading Notification Department of Punta: Health- Childhood Lead Poisoning Prevention Program
Deleading Notification
?lease complete an sections of this form clearly. Incomplete or illegible forms will be returned.
pI, I
I .J Id UO Inspection Date Nf��' 19
._rd ?aimispe,.o:�l I Gl(- _ Iicensc=
raper:;: Owner Pti, ,5 ;' s; . 1olooa
4
Proper--Owner's Address �9 lattii0^c Lan, i ) ZipCode
u o ec person performing work: ,4n __dip Lick:Auth.k I66tj
Address a�uperso 7 on Vt - 61proa M} _ Zip Code_fh'4C
o ne Number ill. b _SS qe3�__---
Address where the work will be done:
BcP:din_Name (if ans.: Floor
Street Address 396KaYe5 TttYE . Apt No.
MoilPUMtP-rpN,#14 Zip Code Ci O60 The property is a t../multi-family_single family.
Deteadine Method(s):
▪ Making pain:stat:if.Ig: risk) _ Making paint intact(moderate risk) f Component removal(sow risk
a. Denton:io:: Liquid encapsulant components
• ScrapCovering al Other:Compete: :::emovacreplacement _ Capping baseboards
gi Dipping _ Applying vinyl siding on exterior
The work will:begin on f Zia and will finish by c:2( q The work will be done in the '-Ya:n sibm or__weekends
in Cases Emergency Comae: pow, KA-cc
Sef3-47fl-3313 Evening Phone Aw.-z
e Prooerri Owner must complete and sign the following information:
o Lica persons 'ave compiled with the training requirements of the Massachusetts Lead Poisoning P ever:ion
dontrol R 6. aro. s. ib CMR 460.003. on: conduct deleading work. I further cenity that the authorized person(s)will not exceed Ode Sc'
of her thothoriro and will be performing only those activities indicated above. All of the information contained in this document is ace
commit _.- -est c:my.c:owiedge and be,:ei
'PO/� �(q „gneG
The following people;agencies must be notified ten days before beginning work: •
.,edI:bar:s Or'the dwei_ingunit
_. All sone:nocronarts of use residential premises. if any work will be done in the common areas
3 Child^.00n. Lead Poisoning Prevention Program. DPH Fax 178:1774-6700
P^7n
R: :.ac.ca S tee:, Canton.. MA. 030
o stns ang Legii Proorann. DLS
- Sitanifgrig Sior Boston. MA 02 SUBMIT ONLINE AT:
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Lidzai 3dartir of Healing:Code Enforcement o e v
_.,_ Crro ,.. ro, .e ya _r or Historic aces.HIE the MA Histocca. Commission.at(6:7)727.8470.