HomeMy WebLinkAboutMiscellaneous - 209 HIGH STREET 4/30/2018DEPARTMENT OF PUBLIC HEALTH/DEPARTMENT OF LABOR & INDUSTRIES
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 S197
FILE NUMBER
Lead Paint Inspector John Carroll #12516 _ate of Inspection 5/19/93
Contractor performing project Lead Busters, Inc. License $ DC 000005
Address of Project
Building Name (if any) Floor
Street Address 1209 --High -Street.; Riaht side (vacant) Apt. No. Duplex
cit North Andover Zip 4a -X11-94 O
Y
Deleading Method: . DRY SCRAPING HEAT GUN ENCAPSULATION DEMOLITION
(circle all that apply)
POWER SANDING CAUSTICS REPLACEMENT OTHER
If "Other" selected, please explain
Check one: dwelling is Multi—family
Start date 6/7/93
2/fa_m- ily
single family
Completion Date 6/7/93
When will work be.done: am X pm X weekends?
Project Supervisor Name Lance E. Liberae
Property Owner Clair Daigle
Address
City
58 Tgater Street
N. Andover
Telephone 508-686-9112
State MA
License I DS 000130
Zip
In case of emergency, contact what person: Pdtricia-A. 'Marrin
Phone: Area code required day (617) 592-5323 evening (617) 592-9602
(OVER)
0034B/5 rev 11/16/89
In accordance}with Chapter 773 of the Acts of 1987, Massachusetts General L s
C. 111 5197, 454 CMR 22.00 and 105 CMR 460.000, notice of the date and met01m*f
removal or covering of paint, plaster soil or other accessible material con ainin
dangerous levels of lead, is to be provided to the following persons at leas e
days prior to the beginning of deleading.
1. Occupants of the dwelling unit
2. All other occupants of the residential premises, if any
3. Director, Childhood Lead Poisoning Prevention Program
Department of Public Health, 305 South Street, Jamaica Plain, MA 02130
4. Lead Removal Program, Bureau of Technical Services
Department of Labor and Industries, Division of Industrial Safety
100 Cambridge Street, Room 1101, Boston, MA 02202
5. Local 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 recd
and understood the Commonwealth of Massachusetts Deleading Regulations, 454 CMR
22.00, and Lead Poisoning Prevention and Control Regulations, 105 CMR 460.00, and
that the information contained in this notification is true and correct to the best
of his/her knowledge and belief.
Date June 2, 1993 Signed:
Title: President/Contractor
Company: Lead Busters, Inc.
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0034B/6 rev 11/16/89
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