HomeMy WebLinkAboutMiscellaneous - 20 CARTY CIRCLE 4/30/2018 / 20 CART CIRCLE
2101047.0-0033-0000.0
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Address_ G,�-Q?� C-'
Title of File
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Date File Open: Gate die closed:
Doc Document/Action Tifile Date of kefer to other Purpose of Document/Actio
action Document/ document/ nand notes
1Wum• Action Department
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Board of Appeals — Board of Health Planning Board _ Conseruaton Commission —
Bonding Department ------__
Department of Public Health/Department of Labor & Industries
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NOTIFICATION ICATION OI: DELUADING WORK ��HE�fTH
All sections of this IUnll I,,ust be cullip1cted 111 ordcr to Colliply with 1 j l
tits notilicatitnl reyuircntcmts of M.G.L. C. I I 1§197, t
454 CN1R 22.00 and-105 CNIR 460.000, as most rcuentIv an)cndcd
Contractor perfonning project Dec—Tam Corporation —License # DC000470 Exp Datc 12/13/96
Lead Paint Inspector Diane Ciano License 9 13146 (6/1/96)
PROPERTY OWNER If owner or unlicensed owner's agent will be perfonning low-risk deleading�curk,com)picic the following):
Property Owner Agent(s)
Address
Telephone Number
I certify that I have complied with the training requirements of the Commonwealth of Massachusetts Lead Poisoning Prevention and Control
Regulations, 105 CMR 460.175,for owner/agent low-risk abatement and containment. I further certify that I or m)•agent will be performing the
following low-risk activities(I have circled all that apply):
applying liquid encapsulant capping baseboards removing doors,cabinet doors,shutters
applying exterior vinyl siding covering surfaces
I certify that all the information contained in this notification is true and correct to the best of my knowledge and belief.
Date Signed
ADDRESS OF PROJECT:
Street Address 20 Carty Circle Apt. Number
City �No. Andover Zip 01845
Property Owner Shirley & Stan Fung Address 700 Bullfinch Drive — Andover, MA 01810
Telephone Number (508) 686-4887
Deleading Method: Wet/Dry Scraping Heat Gun Liquid Lucapsulaiil
Demolition Caustics Replacement
Covering Other
If"Other"selected, please explain chemically strip off site
Check one: Dwelling is multi-family Single-family X
OUier
Page 2 of 2
Mart Date 7/25/96 Cuntpleliun Datc 8/2/96
,When will work he done: am 8 pm 5 (Sllccilj•times un site) %VeekendS? no
f
project Supervisor Nene
Dennis Fallon Liccnse„ AS448 l;�l, late 1/4/97
Worker's Comlaensatiun Pohcv Number WCP0005948 Carrier Eastern Casualty Ins. Co.
in case of emergency contact Dennis Fallon (Conlraetur's Represcnlalive)
in accordance with Massachusetts Gcnc+ •i Ln\v,C. I i 1 §197,454 CMR 22.00 and 105 CMR 460.000,notice of the date and mcthod(s)of rcinoval
or covering of paint,Master or other accessible materials containing dangerous levels of Icad isto be provided and must be received by the follo%ving
agencies,at least TEN days prior to the beginning of dcicading. NOTIFICATIONS MAY BE FAXED.
1. Department of Labor 8c industries,I)ivisiun of Asbestus/Lead licensing and Enforcement
100 Cambridge Strcel,Room 1106, 13oston,MA 02202 FAX (617)727-7568
2. Director,Childhood Lend Poisoning Prevention Program
Department of Public I lealth,470 Atlantic Ave.,Boston,MA 021 1 1 FAX (617)753-8436
3. Occupants of dwelling unit
4. All other occupants of the residential premises,if any
5. Local Board of Heahh/Code Enforcement Agency
6. Massachusetts Historical Commission (if premises are listed on the State Register o1,I-Iisturic
220 Morissey Blvd. Places,this notification must be made upon receipt of an
Boston,MA 02202 Order to Correct Violations or at least 30 days prior to
FAX(617)727-5128 initialing I)revcutivc deleading)
DELEADING CONTRACTOR
The undersigned hereby states,under the pains and penalties of perjury,that.he/she has read and understood the Conunonweallh of
Massachusetts Deleading Regulations,454 CMR 22.00, and the Lead Poisoning Prevention and Control Rcgulatious, 105 CN1R
460.000,and that the information contained in this notification is true and c Tect to the b_ ,t/off his/lier knowledge and belief.
Date 7/2/46 Signed
CompanyNamc Dec—Tam Corporation -s
Address 10 Lowell Jct. Road — Andover, MA 01810
Telephone Number (508) 470-2860
NOTIFICATIONS SHALL BE COMPLETED IN THEIR ENTIRETY,DATED AND SIGNED - INCOMPLETE
NOTIFICATIONS WILL NOT BE ACCEPTED AND WILL BE RETURNED BY D.L.I.
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