HomeMy WebLinkAboutMiscellaneous - 27 WILSON ROAD 4/30/2018 (4)J
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DEPARTMENT OF PUBLIC HEALTH/DEPARTMENT OF LABOR & INDUSTRIES
NOTIFICATION OF DELEADING WORK
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All sections of this form must be completed in order to comply with
the notification requirements of M.G.L. C. 111 $197
FILE NUMBER
Lead Paint Inspector '. ; �C*ate of Inspections--�,:'
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Contractor performing project ), ;"." ` ,�': -�, License #�; "� LJV0 3
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Address of Proiect
Building Name (if any)��
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Street Address
Cit
y V Zip
Deleading Method: DRY SCRAPING HEAT GUN ENCAPSULATION DEMOLITION
(circle all that apply)"a,,,,___- -�
POWER SANDING CAUSTICS REPLACEMENT OTHER
If "Other" selected, please explain
Floor
Apt. No. ! 4 -
Check one: dwelling is Multi -family b`f
Start date ti /.? / t 7 -
single family
Completion Date
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When will work be. done: am pm j weekends?
Project Supervisor Name
Property Owner A4 a 1. X41 �"`. i (J^J c A
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License # 31 (I r .i •.,% 7d -
Address `,1` j` i -; f., f. r
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City �� 4 ��. �0-r,�- State r Zip
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Telephone? = t, 7 %
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In case of emergency, contact what person:
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eveninPhone: Area code required day g-
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(OVER)
0034B/5 rev 11/16/89
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In accordance with Chapter 773 of the Acts of 1987, Massachusetts General Laws
C. 111 §197, 454 CMR 22.00 and 105 CMR 460.000, notice of the date and method(s) of
removal or covering of paint, plaster soil or other accessible material containing
dangerous levels of lead, is to be provided to the Iollowing persons at least five
days prior to the beginning pf deleading. v�
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1. Occupants of the dwelling unit 41 14
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 reed
and understood the Commonwealth of Massachusetts Deleading Regulations, 454 CMfi
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 i% Signed:
Title:
Company:
— — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — —
Office Use Only
0034B/6 rev 11/16/89