HomeMy WebLinkAbout0036 WALNUT STREET (HYANNIS) - Health 35 WALNUT ST. HYANNIS
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NO'.IFICATION OF DELEADING WORK
All sections of this form must be-completed in order to comply with
the notification requirements bf M.G.L. C. 111 S197
FILE NUMBER
Lead Paint Inspector Date of Inspection 9�
Contractor performing project Gti[C� License t .YC• C)005bi
Address of Proiect
Building Name (it
any) Floor �^
Street Address tW__3 _ Apt. No.
City (rVU ^ Zip 2—
Deleading ethod: DRY SCRAPING BEAT GUN ENCAPSULATION DEMOLITION
(circle all that apply)
POWER SANDING CAUSTICS OTHER
If "Other" selected, please explain
Check one: dwelling is Multi-family single family__
Start date ` >L 5 ,� Completion Date C S.
When will work be done: am pm weekends?
Project Supervisor Name _ 'VC0)7��'� License I
Property OwnerYD y
Address ,_ ���j��l_�►�} p
City 1i State s C Zip 02�3�--
Telephone_
In case of emergency, contact what person:
Phone: Area code required day_ (�� �j evening
(OVER)
0034B/5 rev 11/16/89
Act- c= 19E7. Massa=nugo-_.
C. l S-a- , 4 Ss C.-JR Z_.00 and 105 =:.c 460.000, notice of the date and me_non l si c:
removal o: covering paint, plaster soi! or other accessible material contairina
dangerous levels of load, is to be provided to the following persons at least five
days prior to the beginning of deleading.
1. occupants of the dwelling unit
2. All other occupants of the residential premises, .it any
3. Director, Childhood Lead Poisoning Prevention Program
Department of Public Health, 305 South Street, Jamaica Plain, HA 021-30
4. Lead Removal Program. Bureau of Technical Services
Department of Labor and Industries, Division of Industrial Safety
100 :amaridge Street, Room 1101, Boston, MA 02202
5. too—c-I 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 rend
and understand the %-~-=enweelth of Massachusetts Deleading Regulations, 454 CMR
22.00, and Lead Poisoning Preven-..ion and Control Regulations, 105 CMR 460.00, and
that the imlc_r=tion contained in -lis notification is true and correct to the best
of his/her knowledge and belief.
Date Signed:
Title:
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Office Use Qrly
00348/6
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