HomeMy WebLinkAboutMiscellaneous - 30 CHURCH STREET 4/30/2018 (2)N
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DEPARTMENT 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 5197
Lead Paint
Contractor
FILE NUMBER
Inspector Zze- sz lzr- 6AU11-1q Date of inspection
Performing projectk1i/-1A6Z7 6-6r
,,r -Al License
P,-2-<-r/i P A--rJ A /
Address of Project U
Building Name (if any) Floor
V/.% H -
Street Address D( r M S
OR Apt. No.
Cityojcn� zip-
/-a-
#-36S
Deleading Method: HEAT GUN ENCAPSULATION DEMOLITION
(circle all that apply) (��
POWER SANDING ETICFS) REPLACEMENT OTHER
If "Other" selected, please explain
Check one: dwelling is Multi -family single family- L// -
Start dat - 416 Completion Date
When will work be done: am Pm weekends?
Project Supervisor NameURPO H, U�016AJD License #
Property Owner K K
Address -S C 740 < C 4 .1 -IST
City- �WFTR PAMWEr State
H A zip C1 (R4/�s
Telephone 627-17sri
In case of emergency, contact what person:
Phone: Area code required da&. I �) d, 15- 776 R evening
(OVER)
0034B/5
rev 11/16/89
.11
In accordance with Chapter 773 of the Acts of 1987, Massachusetts General Laws
C. 111 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 other accessible material containing
dangerous levels of lead, is to be provided to the following persons at least five
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
S. Local Board of Health/Code Enforcement Agency '
6. Massachusetts Historical Commission
I., (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 CMR
22.00, and Lead Poisoning Prevention and Control Regulations, 105 CMR 460.00, and
that the information containe d in this notification is true and correct to the best
of his/her knowledge and,belief.
Date Signed:
fi
Title: P 0
Company:
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Office Use Only
0034B/6
rev 11/16/89