HomeMy WebLinkAbout0050 FOSTER ROAD - Health Hyannis —
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Department of Public Health-Childhood Lead Poisoning Prevention Program
Deleading Notification
Please complete all sections of this form clearly. Incomplete or illegible forms will be returned.
Lead Paint InspectorFIC6�2Z51Q C h/ l'l ` A License#(�l�734 Inspection Date
Property Owner 29/4_l/f A) S' /��yG/� G-Z_OX14 eDl/�i�1�
Property Owner's Address A-47 &,VIA Zip Code
Authorized person performing work: ef/t Lic#/Auth.#jGZ/s-60/y
Address of authorized person ` 6 0o Zip CodeC> vZ?3
Telephone Number L605 A
I
Address where the work will be done:
Building Name(if any) Floor
Street Address "'4 PfO g 7F/L D f0 Apt No.
City t IlW .Zip Code6,7_r,:,v I The property is a_multi-family K single family.
Deleading Method(s): ,
❑ Making paint vintact(high ❑ Dipping ❑ Applying vinyl siding on
risk) ❑ Making paint intact exterior ,
❑ Demolition (moderate risk) /)W Component removal(low
❑ Scraping ❑ Liquid encapsulant risk components)
Component A Covering ❑ Other:
removal/replacement ❑ Capping baseboards
The work will begin m O& and will finish by�% %f�The Work�be dbiie in the S am�c_pm or. weekends.
In Case of Emergency Contact
Daytime,Phone f o; =3 yr..-,.s /,z S Evening Pho 6 03—
3S«1—SI,Z °J
The Property Owner must complete and sign the following information:
I certify that only authorized persons who have complied with the training requirements of the Massachusetts Lead Poisoning
Prevention and Control Regulations, 105 CMR 460.000,will conduct deleading work.I further certify that the authorized
person(s)will not exceed the scope of his/her authority and will be performing only those activities indicated above. All of the
information contained in this document is true and correct to the best of my knowledge and belief.
Date - Signed
The following people/agencies must be notified before beginning work:
1. Occupants of the dwelling unit
2. All other occupants of the residential premises, if any work will be done in the common areas
/3. Childhood Lead Poisoning Prevention Program,DPH Fax(781)774-6700
5 Randolph St,Canton,MA 02021
/4. Asbestos and Lead Program,DOS
19 Staniford St, 1s`Floor,Bostori;Mk 021-14 Fax(617)626-6965
(/ 5. Local Board of Health/Code Enforcement Agency
*If the home is on the State Register of Historic Places,call the MA Historical Commission,at(61.7).727-8470.:
47
-SEP-,9-2010 01:19P FROM:CSD 5083e53909 TO:15087906304 P.1
C;zLEAN SURFACE DELEADIN.Gr INC . -
203 Essex St. (781) 340-0816
Weymouth, MA 02188
FACSrMILE COVER SHEET
DATE: 9/19/10
TO:' Director, Asbestos 6 Lead Program
(617) 626-6965
Director, Childhood Lead Poisoning Prevention Program
(781) 774-6700
Board of Health, Town of Hyannis
(508)790-6304
FROM: Mark S . Bianco
RE: Notification of Deleading Work
50 Foster Rd. , Eyannis, MA
PAGES: 3
Please call (781) 340-OB16 if any problems with transmission.
�,SEP- 9-2010 01:19P FROM:CSD 5oe3853909 TO:15087906304 P.2
COMMONWEALTH OF MASSACHUSETTS
Department of Labor&Industries and Department of Public Health
NOTIFICATION OF DELEADING WORK
All sections of this form must be completed in order to comply
with the notification requirements of M.G.L.Ch. i l l, § 197,
454 CMR 22.00 and 105 CMR 460.000 as most recently amended
File Number. (AGENCY USE)
Contractor performing project Mark S.Bianco License#DC 001055
Lead Paint Inspector Frederic J. Hemmila License#2736
Date of Inspection 7/17/10
If low-risk deleading work is being performed,complete the following line:
Property Owner: N/A Agent:
Address of Project
Building Name(if any) Floor
Street Address 50 Foster Rd. Apt.No. N/A
City Hyannis Zip 02601
Deleading Method: �Covering
g Heat Gun cs
Liquid Encapsulant Demolition Replacement Other
If"Other"selected,please explain
Check One: Dwelling is multi-family Single family X
Start date 9/29/10 Completion date 10/6/10
When will work be done: A.M. X P.M. Weekends X
Project Supervisor's name Mark Bianco License# DC001055
Property Owner Brian Meyer
Address Box 509
City So. Sutton State NH Zip 03273
Telephone (603)344-5126
In case of emergency contact Cathy Bianco
Phone: day_ (617)426-3600 evening (781)340-0544
(over)
. _:SEP19-2010 01:20P FROM:CSD 5083853909 T0:15087906304 P.3
Pa"e 2 of 2
In accordance with Maseaebe did Geasaal ti =C.1111197,434 CbM 22M sad 105 CM R 4f&M oatles of the dote mud sedbod(s)of
remove]or covens"of psis,plater or other awsible atateriab eoatainia8 dangrrvw b:veb of kad Is to be provided sad ant be reedved
by the foUowtag agents,at leant]{(10)days prior to the begleafsa of dekadla8.
NOTMCAMNS MAY Big FA71 M
1. Deportment of Labor,LeadProgram.Dfvdlmt ofOccepadonal Safety
19 Stamford Street,Y'F1oor,Roston MA 02114 FAR:617.6264M
2. Director,CbMbood Lead Pokonin"Prevention Program
Department of Public Health,Dmavae HaM Hutldfn S Randolph Street,Cwton,MA WMl FAX 78I 77"700
3. Oaapaab of dwdOng"it
4. All other eeenpaate dike residential pre mb s.it any
S. Loa]Bond of Haft ACode Refateeaeat Agency
C Maaadrruetb IBttorlieal Comstuim (If premba an listed at Me State Register of Hbtork
22D Morwiuey Bkd. ]law,tbb aotificatioa seat be made upon receipt of m
Boston,MA 02202 Order b Correet Violations or at frra U 30 days prior to
FAX(617)727-d128 billatiss preventive delesdhW
NIO UICATIONl4 SHALL BE COMtI3v=IN TMR)F9V7IREIY,DATED AND SIGNS-IN1C0110PI Z NOIUWA71ONS WILL NOT
BE ACCUM AND WI L BE RETUR M BY IW DWAB1NMr OF II.ABOR A WORM .
ZRQMMCMNM(IfuwmrorudiacmdowncesapmwiUbeFmfarml glow-ri*deleedhtg wor44 complete the CdtoviW:
Property Owner A"cnt(s)
Address
Telepbooe Number,��-
i
I exrt*that I have complied wide the training rogrBraanerrb ofd o CommoniNu tlh of Mesemkoft Lad Pobonmg Pmvention and Comrol RegatWon%105
CWR 460.175,for ownerigpd kw-d lc abatement and cooWmaut 1 f Wiv car*dot I or my siput will be performing the f lowing luvwriA advities
(I bave circled all beat apply):
applying"sgald ampsubat appisg baeboards reauving doom,tabint door,sbnttea
apply!"esterbr vbyl deals averias ear0rea
I ea*thall ifomtton go nd is b notation i,tu ad oorxt to he best of my knowledge ad bof
Date inform
Siped ,/,
Revised 12/2007