HomeMy WebLinkAbout0420 WEST MAIN STREET - Health 420 WEST MAIN , NI
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COMMONWEALTH OF MASSACHUSETTS
Department of Labor & Industries and Department of Public Health
NOTIFICATION OF-DELEADING WORT{
A11 sections of this form must be completed in order to comply
with the notification requirements of M.G.L. c.11l 5 197,
454 CHR 22.00 and 105 CHR 460.000 as most recently amended
FILE NUMBER: (AGENCY USE)
Contractor performing project ST UE y� ,9 R !J AT i Ucense # -D C 000G I (p
Exp,datei_0 r
Load Paint Inspector �G���y�, License V
Date of Inspection `�L
If low-risk deleading work is being performed, complete the following line:
Property owner Agent(3)
Addroaa of Project
Building Name (if any) Floor
Street Address
Apt. No.
City Wy47_V,1V-17_-5 Zip
Deloading Method: Wet/Dry Scraping Heat Gun Caustics
Liquid Encapsulant overin Demolition eplacemen Other
If "Other" selected, pllease explain
Check One: dwelling is multi-family single family
Start date / /� f� /Completion date /o� • /�
When will work be done: A.M. _ c/ P.M. Weekends?
Project Supervisor's name .STG:J(F 8AR QA 11 License
Property OwnerQIZ
Address ry)
F -City State /17? Zip .6a,
Telephone -w
C
In case of emergency contact S`ig Ue BA Qr0_1T I
Phone: day(j�'VY)?��ft(-�q 5`� evening{50s)3gq 5 yO( 5
',3Y.. 9770 C R. ~
(over)
w
a+;,:Ordo I o:o with MaSsachusaCts Aanaral Laws 111 3 t')? CMR _ .0+1 ,and 105 'td:; If)O.at)1 nutico
J A the d1to and method$(S) Of CemOVal OC COVeCIng Of (?d1i1C, 111.15CdC Or 0C11--1 W,,esziblo material;;
"ontainin+) dangerous levels of lead is to be provided and must be received by 0- ;ollr,win,
persons, at least ton (10) days prior to beq mniny of deleading.
1. O-;cupants of the dwelling unit
_'. All QthPr occupants of the casidentiai premises, if any
3. DireCCOI, Childhood Leading Poisoning Prevention PLogram Fax 61": 753-6436
Department of Public Health, 470 Atlantic. Avenue, Boston, MA 02110
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4. DirecCOr, Asbestos 6 Lead Program tax t6171 '117-750
Department of Labor 4 Industries
Room 11006, 100 Cambridge Street
Boston, MA 02202
S. Local Board of Health/Code Enforcement Agency
6. Massachusetts Historical Corunission (If premises is listed on the State Register
220 Morrissey Blvd. of Historic Places, this notification must be
Boston, MA 02125 ma(3e upon receipt of an Order to Correct
Vlolatioos or dt least 30 days prior to
initiating preventive deleading)
Fax (617) 727-5128
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 best of his/her knowle ge and belief.
Date
Title:
�p1�
Company: /1���(� 7 f)TN i ernn Ufa i_ S YS ing-lY,S
Property Ownsr (If owner or unlicensed owner's agent will be performing low-risk deleading wOCK)
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 perforating
tits followin3 low-risk activities (I have circled all that apply)
F' applying liquid encapsulant cap
ping haseboarus
applying exterior vinyl siding covering sk-faces
remoJing duOLS, cabinet doors, ShutteC9
I r:ertify that all tlN in(,,rn+aCl � , rtainet 1 teas • . i(.,atr� t is tc .y .+na to tho
best Of my know)edgH anti bellef.
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