HomeMy WebLinkAboutMiscellaneous - 40 Sunset Rock Road " 1
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Department of Public Health-Childhood Lead Poisoning Prevention Program
Deleading Notification
?lease complete all sections of this form clearly.Incomplete or illegible forms will be returned.
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Lead Paint Inspector Nw—I �laclomA'l License# - _Inspection Date__ i
Property Owner A U I-& L
Property Owner--s Addres�'- f=f— oLC �occr%Q l�Gv Zip-Code Q IY/ y
t cP, L u Lic#/Auth.# 0 F3 � Cf
,'authorized person performing work: � �
Address of authorized person 40 5u vt Cy Zip Code U l S-i O
Telephone Number(__)_cj7F a5-7 32(
Address where the work will be done:
Building Name(if any) Floor 12
Street Addressa7 Afa/N STetf Apt No.
City /VO274 jA?n da2-*", Zip Code !� BYS The property is a_multi-family single family.
Prb perz'� 13 LliClinf
Delead �Meth3dis):
❑ Making paint intact(high risk) D Making paint intact(moderate 0 Applying vinyl siding on exterior
o Demolition risk) le—o-� Component removal(low risk
o Scraping o Liquid encapsulant components)
• Component removal/replacement Covering a Other:
• Dipping o Capping baseboards
The work will bean on_/ /1 and will finish b}_/ / The work be done in the am_pm or_weekends.
In Case of Emergency Contact�j� Lu
Daytime Phone I?ZX o?S7 —3a 67 Evening Phone q 7 y7J`�y0
The Property Owner must complete and sign the following information:
I certify that only authorized persons who have complied with the training requirements of the Massachusetts Lead Poisoning
Prevention and Control Regulations, 105 CMR 460.000,will conduct deleading work.I further certify that the authorized
person(s)will not exceed the scope of:his/her authority and will be performing only those activities indicated above.All of the
information contained in this document is true and correct to the best of my knowledge and belief.
Date_ /2} 20v7 Signed
7�
The following people/agencies must be notified ten days before beginning work:
1. Occupants of the dwelling unit
2. All other occupants of the residential premises,if any work will be done in the common areas
3. Childhood Lead Poisoning Prevention Program,DPH Fax(781)774-6700
MWRHO
5 Randolph St,Donovan Building
Canton,MA 02021
4. _Asbestos and Lead Program,DLWD
399 Washington St.,Boston,MA 02108• Fax(617) 727-7568
5. Local Board of Health/Code Enforcement Agency
If the home is on the State Register of Historic Places.call the MA Historical Commission at(617)727-8470.