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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
FILE NUMBER
Lead Paint Inspector JILT '-bil ytu l hY-D Date of Inspection /
Contractor performing project OV6 -- License
Address of Project
Building Name (if any) Floor
Street Address % 3 �W 157 Apt. No. � 4�
City /y0o�- 1'W0'1(YA_ .. Zi
P
Deleading Method: DRY SCRAPING HEAT GUN ENCAPSULATION DEMOLITION
(circle all that apply)
POWER SANDING CAUSTICS REPLACEMENT OTHER
If "other" selected, please explain
Check one: dwelling is Multi -family single family
Start date /�� �C1f Completion Date—//3//5;
When will work be done:..am pai weekends?
Project Supervisor Name ry i License
Property Owner `%y'`l��r� eA'�L(sTZJ
City✓C-rK�, 11 State V._ Zip
Telephone
In case of emergency, contact what person:Y✓llti
Phone: Area code required day _,�6 - 23 evening ZMkz'
(OVER)
0034B/5 rev 11/16/89
In accordance with Chapter 773 of the Acts of 1987, Massachusetts General Laws
C. 111 5197, 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.
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 CMrt
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 %/_ 71 Signed: f ..
Title: OWN crit.
Company: - %,r' 1� -ly-oleycf--
--.. -- ——-.------
Office Use Only — ---
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0034B/6
rev 11/16/89