HomeMy WebLinkAbout0033 SUNNY KNOLL DRIVE - Health 33 Sunny Knoll
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COMMONWEALTH OF MASSACHUSETTS
Department of Labor 6 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. c.111 S 197,
454 CHR 22.00 and 105 C24R 460.000 as most recently amended
FILE NUMBER: (AGENCY USE)
Contractor performing project Vtvm2 License # DC •
Exp.date 19 9
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Lead Paint Inspector License # 17-3(Q
Date of Inspection
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 sa-J-6644A41411. � _ Apt. No.
Zip O Z6 O /
City
Deleadin Method Wet/Dry Scraping Heat Gun Caustics
Liquid Encapsulant Covering Demolition Replacement Other
If "Other" selected, please explain
Che,:k One: dwelling is multi-family single family y
Start date �,T 1 G Completion date
When will work be done: A.M. 1/ P.M. �� Week ds?
Project Supervisor's name L License # D(�- CQMS�
Property Owner
Address
State Zip dZ l (
city / '-7
Telephone 17 - / o-�} O/
In case of emergency contact
Phone: day - n b j evening
(over)
In accordance with Massachusetts Ceneral Laws c. Ill 4 197 CMR 22.00 and 105 CMR 460.000 notice
of the date and methods(s) of removal or covering of paint, plaster or 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 •)f the dwelling unit,
_. All other occupants of the residential premises, if any �^
3. Director, Childhood Leading Pois-Dning Prevention Program Fax (617) 753-8436
Department .-if Public_ Health, 470 Atlantic Avenue, Boston, MA 02110
4. Director, Asbestos 6 Lead Program Fax (617) 127-7568
Department of Labor 6 Industries
Room 11006, 100 Cambridge Street
Boston, MA 02202
5. Local Board of Health/Code Enforcement Agency
6. Massachusetts Historical Commission (If premises is listed on the State Register
220 Morrissey Blvd. of Historic Places, this notification must be
Boston, MA 02125 made upon receipt of an Order to Correct
Violations or at least 30 days prior to
initiating preventive deleading)
Fax (617) 727-5128
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Deleading Contractor
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 est of is/her knowledge and belief.
Date 1 3 � � Signed:
Title:
Company:
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 encapsulanr rapping baseboards
applying exterior vinyl Tiding -overing surfaces
remr,vina doors, .-abin"t •A u:s, shutters
I .certify that all the inf0rmati1)r1 `ontained in this notifi-%it iOn is true and correct to the
,f my I:n':.wledge and
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