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HomeMy WebLinkAboutMiscellaneous - 22 BIXBY AVENUE 4/30/2018 t22 BIXBY AVENUE 111 2101969.0-0004-0000-0 From:GARY ONEILL Fax:(855)728-4522 To:+19786888476 Fax: +19786888476 Page'2 of'2 0510312016 3:3^o PM I*P"MLat of PubHe Health&Department oflAbor Fix . Narlr+tcATtoN of D>rI.EADnrc wORIC , i All sections orehis form m be completed In order to comply wttb a' the notification requirements or M,G.L-.C.1111197, 454 CMR 22.69 and 105 CMR 460.000,s11 most recently amended v . Contractor performing project, �7�v/ © c-1G L Licenac d—�Eap Lead.Paint inepaetor� l�/ G� Date of Inspection Lleanso N Dol Ezp DaOe/�4/5�"/'f(�, Street Addram-2 b /7K 6 Y ,;g pt.Number ��s City �l���i PropertyOwner p /y Z-39 ,3 11'ele bass Namhar i)alesding Method: et/Dryr Scraping ®Heat con raid El11tap11tslenl' [ Demolition ®Caustics �,�mplstceatant [,Covering ®Other If"Dthor"selected,picam,explain Check one: Dwallling io m/uld-fbmily Single•ihmily= .per :Stsrtbatm`: J "�7",�j Completion Date ��l6— �. When will work be done: AAf��PM �(Spsclly thea on site) Weekea.dst Project Supervisor Nemo G�/�/� �/j/(��-fG, License 02� Esp.batot� Worker's Compen11atlnn Policy Number Li Be5�4 In case of emergency eootact ���_ y( c, /z, ' M ( /7 ✓� �,Q (Contractor's Representative) The undersigned hereby states,under the pains and penalties of perjury,that 110/11641 has road and understood the Comaaanrrea6h of Manschwetts Daleading Regulations,454 CMR 22.00,and the Lead Polsonhng Prevention and Control Regalotfon41,flog CMR�0,0w,and e, that the Information contained in this notification Is true and correct to the best of bla/hor knowledge and belief. B e. Date ! / 3lgnmd , Company Namej/V4-1 6PA, Addrea_ ,/aJG7v��C�,/tl' /�Z� S�GGnr / dVG` Telephone Number �v f I Received Time May, 1 2016 7: OOPM No. 1721