HomeMy WebLinkAboutMiscellaneous - 30 BELMONT STREET 4/30/201804
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DEPARTMENT OF PUBLIC HEALTH/DrIPARTMENT OF LABOR & INDUSTRIES
marIFICATION OF DELEADItIG WORK
A1.1 nectiolls of thiq rot:m must 1- COMPI-ete�(l in order to COMPIY with
the notification requirements of M.G.L. C. 111 5197
F11,r NUMBER
Lead Paint Inspector Lt6 Date of Inspection
Contractor performing project�-hA,,� tL� License ln-c-.000-tf.�-L
Address of Project
Floor
vulluing mame L. anyj- N
Apt. No.
Street Address --_:-D-- A -P — -- --- 1��
City zi
CAPSULATIOt
Deleading Method: �R S �CR;�It I HEAT GUN DEMOLITION
(circle .111 that apply)
POWER SANDING CAUSTICS REPLACE;1ENT-) OTHER
If "OLher" selected, please explain
Check one: dwelling is Multi -family single family
L-1 - s- - -� I
Start date P) Completion Date A 6
When will work be done: am (UL/ weekends?
Project.Supervisor Name
Property Owner
Address
License
City SLiLe
zip
Telephone
In case ot cmergency, contact what person: �aa
Phone: Area code required day,
(OV r 11)
ovening -1 � L ( - ci S-3 (-,
In accordance with Chapter 773 of the Acts of 1907, Massachusetts General Laws
c. ill S197, 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 oLher accessible material cotitaining.
dangerou I s levels of lead, is to be provided to the following person-, at least rive
days prior to tile beginningi)f deleading.
I . Occupants of tile dwelling unit
2. All oLher occupants of the residential premines, 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 Ilealth/Code Enforcement Agency
6. massachusetts Historical Commisgron
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(if premises is listed on the SKc,' —Lgister of Historic Places)
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The undersigned hereby states, under the pe ItLes of perjury, that s/he ha-,; - d
VNPI
and understood the Commonwealth of Massachusetts Deleading itegulations, 454 CMR
22.00, and licad Poisoning Prevention and Control Regulations, 105 CMR '50.00, and
that the information contained in this notification is true and correct to the best
of his/her knowledge and belief.
Date 2) Signed:
0
Title:
Compa ny -
office Use Only
MEMPM=-�
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11 IN I - .. I ,
gordon Boyd & Company, %qnc
Multiple Line Adjusters & Surveyors Established 1926
TELEX NO 466111
CABLE: BOYDCO
ADDRESS REPLY TO:
GORDON BOYD & CO. INC.
65 MERRIMACK ST. #15
Form of Notice of Casualty Loss to Building LAWRENCE, MASS. 01843
Under Mass. Gen. Laws, Ch. 139, Sec. 313
To: Building Commissioner or Board of Health or
Inspector of Buildings Board of Selectmen
(�bIT/'J7 An446AO A
addresses ( .1
G
Re: Insured: IsyV7,Z.4d IQ
Property address:
Policy No.
Loss of 19
File or Claim No. L o
Claim has been made involving loss, damage or destruction of the above captioned property, which
may either exceed $1,000.00 or cause Mass. Gen. Laws, Chapter 143, Section 6 to be applicable.
If any notice under Mass Gen. Laws, Ch. 139 Sec. 313 is appropriate please direct it to the attention
of the writer and include a reference to the captioned insured, location, policy number, date of loss
and claim or file number.
01
C�p Ac-'/ cj'_�k--1 1�
Title: �'J
On this date, I caused copies of this notice to be sent to the persons named above at the addresses
indicated above by first class mail.
tig 1�11i�ahnwdate
F-�5
CLAIMS IIRRVICII OF
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