HomeMy WebLinkAboutMiscellaneous - 697 WAVERLY ROAD 4/30/2018 (3)N
FILE
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 S197
FILE NUMBER
Lead Paint Inspector,///
rzI?c S Date of Inspection " � J?—
C
Contractor performing project /52F i ,Z61;ren 0
Address of Protect
Building Name (if any)
Street Address
Clty
Zip
Deleading Method: �ftY—SCF�PING
(circle all that apply)
_POWER SANDING
If "Other" selected, please explain
Floor l
Apt. No.
HEAT GUN.NCAPSULATIO DEMOLITION
CAUSTICS c OTHER
Check one: dwelling is Multi -family single family v
Start date % �! Completion Date v J
When will work be.done.-/,—a pm U weekends?
Project Supervisor Name<
Property 0�4ner
Address C
License I 5' `/ -�-'
G"
City Stat lam? — Zip
Telephone
In case of emergency, contact what person:
Phone: Area code required day s�'�'� `7Z�S z evening
(OVER)
In...acco.rdap_ce with Chapter 773 of -the Acts of 1987, Massachusetts Cenecal Laws
C. 111 5197, 454 CMR 22.00 and 105 GIR 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 cc d
and understood the Commonwealth of Massachusetts Deleading Regulations, 454 Wrt
22.00, and Lead Poisoning Prevention and Control Regulations, 105 CMR '50.00, and
that the information contained in this not ifri ation is tr andorrect to the best
of his/her knowledge and belief.
Date+�
3 Signe �-
Title:
Company:
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Office use Only
FORM - SYSTEM PUN[MG RECORD
TOWN OF ANDOV
SEP 77199`i
Commonwealth of Massachusetts
, Massachusetts
System Pumping Record
N -stem Owner SN,stem Location j
UL/
Date of Pumping: �/� ✓ (� �S Quandt} Pumped: C gallons
Cesspool: No I� ,Yes ❑ Septic Tank: No ❑ Yes E3--
System Pumped by:
Contents transferred to:
Date Inspector
License #: