HomeMy WebLinkAboutMiscellaneous - 241 MIDDLESEX STREET 4/30/2018 (2)co
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Department of Public Health/ Depariment of Labor & Workforce De��elopment
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&197,
454 CMR 22.00 and 105 C14Dt 460.000, is most recently amended
Contractor performing projec _ R�tC=ticrirs, Il-CL.icense H =229 Exp.•Date 1/17/2001
Lead P2int )inspector �te/�d!-ftp �cC�'t[� DAte of Inspection 1111100 Licouse M 1 [j?3 -T--,p. Date
ADDRESS OF PROJECT:
Street Address 7,41 6-1 t 00(_ 5/ Apt. Number 51 aSlt
Cit}
,n'o� A_'-� no w' -�
11-1 P
Zip
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kroperty 0,o•ner
.3-C-^:�A-I wtel-E L9—/
Address
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r -t
Telephone Number I ? S ` C71 -5-Z'1 3
Delending Method: We rycra g
Demolition
Covering
if "OtlieC' selected, please e%pliin
Check one: Dwelling is multi -family
Start Date //(Z{a
Hcat Gun
Caustics
-Other
Liquid Encnpsulant
RF�t
Single-family Other
Completion Data
When will work be done: P144- 316 (Specify time.+ on site) Weekends?
Project Supervisor Name ,-i.+ F 0 t L) rz License 4 Q S 3'7 L L Exp. Date /o%/
Worker's Compensation Policy Numbe 17.5674500 Can'ier�liarrp Irs- (D. _
In case of emergency contact. Charles J. Minasalli
(Contractor's Representative)
DELEADING COI TRACTOR
Tel. 46(_ 03 } 329-6101
The undorsigned berehy states, under the. pains and penalties of perjury, that be1she bas read a®d understood the Commonts'eaith of
Massachusetts Delewding Regulations, 454 CMR 22.00, and the Lead Poisoning Prevention and Control Regul2dons, 105 CMR
460.000, and that the information contained in this notification is true and correct to the best of hip1her knowledge and belief.
Date Signed
Company Nime Environmental Restorations, Inc.
16 Hazel Drive Hampstead, NH 03841
Address
Telephone Number 603-329-6101
OVER -4
93 2 7
In accordance with 1�125sachusclis Gen cral Laws 111 $197, 454 CNIR 22.00 and 103 CMR 460.000, notice of the date and
nlethod(5) of removal or covering of paint, plaster or other accessible materials containing dangerous levels of ►cad is to be provided
and must be received by the following agencies, at least TEN ( 10) days prior to the beginning of deleading.
-- - NOMFI-C.kMQNS N,.�-Y RETAXED.
I. Department of Labor and Workforce Developmeut)Division of Occupational Safety
399 Washington Street, 5" Floor, Boston, AA. 02105 FAX (617) 727-7568
2. Director, Childhood }lead Poisoning Prevention Program
Department of Public health, 470 atlantic Ave., Boston, NLd, 02111 FAX (617)753-5436
3. Occupants of dwelling unit
41 All other occupants of the residential premises, if any
5. Local Board of liealthrCode Enforcement Agency
6. hisssachusetts Historical Commission (if premises are listed on the Slate Register of Historic
220 Morrissey Blvd. Places, this notification must be made upon receipt of. an
Boston, MA 02202 Order to Correct Violations or at least 30 doys prior to
FAX (617) 727-51.29 initiating preventive dcleading)
NOTIFICATIONS SHALL BE COMTLETED IN THEIR ENTIRETY, DATED AND SIGNED - INCOMPLETE NOTIFICATION
WILL NOT BE ACCEPTED AND WILL BE RETURNED BY THE DEPARTA-IENT OF LABOR & WOW ORCE
DEVELOPMENT.
hBD2'E',p;TY OWNER (If owner or unlioensad owner's agent will be performing low-risk; deleadutg wurk, complete the foil owin£):
Property Owner Agents)
Address
Telephone Number—(_ )
I ccnify that 1 have complied nidi the trz.ining requirements of the Commonwealth of h4assachu,erts Lead Poisouing Prevention and Control Regulations,
105 C)✓iR 460.175, for owner/agent low-risk abatement and containment. I P.uther certify that l or my agent rill bt performing the following loin -rill:
activi es
4
(1 have circled all that apply):
applying liquid eneapsularil capping baseboard► removing doors, cabinet doors, shutters
11pplying exterior vinyl siding covering surfaces +
I txrdfy that all the inforrnation contained in this notifioQdott is true and correct to the Ml of my knowledgz and belief.
Date Signed
12/99