HomeMy WebLinkAbout0022 PINE AVENUE - Health 22 PINE AVENUE
HYANNIS
('no m/p) _ _ _
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CLEAN SuRrAcE DzLFjw:[ NG, INC .
203 Essex at. Ph: (781) 340-0816
Weymouth, MA 02188 Fax: (781) 337-5346
FACS=LE COVER SHEET
DATE: Nov. 3 2015
TO: Director, Asbestos .& Lead Program
(617) 626-6965
Directors, Childhood bead Poisoning Prevention Program
(781) 774-6700
Board of Health, Town of Barnstable
(508) 790-6304
FROM: Mark S. Bianco
RE: Notification of Deleading Work
22 Pine Ave. , Hyannis, MA
PAGES: 3
WAIVER #15040-NB
Please call (781) 340-0B16 if any problems with transmission.
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-1 WAIVER#15040-NR
COMMONWEALTH OF MASS,ACHUSETTS
Department of Labor& Industries and Department of Public Health
NO'B'II;'.[CATION OF DELEADING WORK
All sections of this forts must be completed in order to comply
with the notification requirements of M.G.L.Ch. 111, § 197,
454 0a 22.00 and 105 CUR 460,000 as most recently amended
File Number: (AGFNCY USE)
Contractor performing project Mark S.Bianco Liceose#DC 001055
Lead Paint Inspector Johnh iae saac License# 2378
Date of Inspection 10/22/15
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_ 22 Pine Ave. Apt.No._
City Hvannis Zip 02601
Deleading Method: W ry Scrap fleet Gu�eplacn=
kcs
Liquid Encapsulant ov Demolition Othe
If"Other"selected,please explain
Check One: .Dwelling is multi-family X Single family_
Start date 11/5/15 Completion date 1211/15
When will work be done: A.M. P.M. Weekends X
Project Supervisor's name .Mark Bianco License# DC001055
Property Owner 362 South St. Trus c o Gary Marad=
Address 25_Qreenteal Way _
City Yarmou State MA Zip 02675
Telephone(508)362-2508
In case of emergency contact Mark Bianco
Phone: day 61 34 - 16 evemng_(781)340-0544 .
(over)
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Page 2 of•2
in Rcordifnet witli Nassachuseits G=eraf Laws C.11I§197,454 CNR 22.M and 105 CMR 460.0@0,notice of the date and method(s)of
ianoval•or twevieg of paint,plaster or other accessibie materiels eadmining dangerousUvels of lead is to be provided and must.be received
by the foNewia$agencies,at least (10)days priorto the beginning ofdeleading.
l+lt3TMCATIONSMAY BE•FAXED.
1- Department of Labor,Lead Program,Division of Occupational Ssifety
19 Standord Street,i"Floor,Boston,MA 02114 FAX:617-626.696E
2. Director,Childhood Lead Poisoning Prevention Pmgrara
'Department of Public-Health,Donavan 1H[ea1Nt Standing,5 Randolph Stre a,Cantan,MA 02021 FAX 791.77"700
3. Occupants of dwelling unit
4. All other occupants.of the residential premises,if any
S. Local Board of Health/Code Enforcom eut Ageney
6. Massachusdts Historical Commission (if premises are listed on the State Register of Historic
220 Morrissey Blvd. Places,this notification must be made upon receipt of an
Boston,MA 0220.2 Order to Correct Violations or at least 30 der prior to
FAX•(617)717-5128 initiating preventive deleadiog)
NOTIFICATIONS SHALL BE COPOLETED IN THEIR Els'jnt 'Y,DATED AND S1GNIM-JN.COMPLETE NOTIFICATIONS WILL NOT
BE ACCEPTED AND'o.L li:$RETURNED BY THE DEPARTMENT OF LA90%t&WORKFORCE DEVELOPMENT.
PROPERTYQM (lfowner or unGtsamd owner's agent will be performing law-risk deleading watts,complete the following):
Property Owner Agerrt(s)
Address
Telephone Number_(___ )-
I acrtify that I have complied with cite training requirements of the Commonwealth of Massachusetts 1 id Poisoning Prevention and Control Regulations,105
CMR 460.175,for owner/agent low-risk abatement sad cabtainment I further certify that 1 or my agent will be perfonaing'the fbilowing low-risk activities
(1 have circled all that apply):
applying liquid•encapeulartt capping baseboards removing doors,cabinet doors,shatters
applying exUrior vinyl siding covering surfaeea
I wrtify that all he information contained in this notification 4 true and Correct to the best of my knowledge and belief.
Bate Signed
Revised 1ZWV