HomeMy WebLinkAboutMiscellaneous - 84 UNION STREET 4/30/20180
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TOWN OF NORTH COVER
Building Departnnent
1600 Osgood Street
Building 2- Suite 2-36 Building Dept
North Andover MA 01845
Tel: (978) 688-9545 Fax (978) 688-9542
COMPLAINT FOR INVESTIGATION
DATE: .13 2o6g TEL #:
NAME OF COMPLAINTA.NT: &4.44.
ADDRESS: 9 VA110Aj S7:
COMPLAINT TYPE:
Electrical:
Plumbing:
Gas:
Building: S:q 1OF6 C.-0 INC. v )O/' JH /,IGGLc f IrAcc, Alb:
Property Owner: 6 FF
Address: 30/00Z, UA/100V c, ne e LT
Other:
44 f A--0yf-0 JAI Do je
Signed: k i
gn d,
Complaint Form - Revised 6.2007
Department of Public fie.alt u' DepartuieAlt of Labor & WorI or ee a velopm
UTNOTIFICATION OF DE LEADING WORI£
All sections of this feria must be completed in order to comply with:
the notification requirements ofAj.G,I L. C. 111§1 97,
454 CIVIR 22.00 and 105 C t7ft 460,090, as ii wt recently alnenrjeri
Contractor perforinin roject ,+u ,leense #
]QntB
Lead I'nint Inspector C.fUAADate of Inspeetion �
d�ice»se # 6/�,�p. 1) ate
ADDIIESS or pftOjrrCT: _
Street Ad
Dumber "`'�"
C't er4•�
)-�-r
roperty Owner 14 1 /J/ a
Telephone Number !O / 9q_165-7 ---
Deleadili letho/1? aping Leat Can
e
_ Caustics
Other
If "Other" selected, please explafii
Check One. Dwelling is Eraulti-fan2ily Single-family i3ther
ulaat
i:`cplacemetilt
Start DAte l ! I Compictlon ,Date
14'hen iwfil ww•lt be done; All'Y Ph (Specify times on site) Weeir�nda7 r
Project Supervisor Name(,c.l
'cense Exp. Date 6
Worker's Cornp!Msatiop Policy Numher Carrier
I
In case of emergency contact Al t A I— 4
(Contractor's Representative)
DELEADING CONTRACTOR
The undersigned hereby states, under the paint; and penaltiNc of perjuj-y, tl►at litgahc Las ,-cad and understood the Contnrowyealti► of
Massachusetts Deleading Regulations, 454 UVIR 22.00, and the bead Poisoning Prevention and Control Regulations, 105 CMR
460.000, and that the informa#on contained in this notification is true and correct to the best of ltislher lalwwledge and helieL
Date Signed
Company blame 661 M ---A
Address_.. ?0,904 oX U t56
Telephone Number 1.�
ni-
Za/ZO :19vi 3_19Vy] TT,07698,R 8'=9T _,'A_0Z/9_T/TT
Page 2 or 2
In accordanre 10t1111machllsetts General Lgws C. 1119197, 454 00 ,22.00 22.00 and 105 Chi R 4 0.000, notice of.ihe duke and
Mctlrod(s) of removal or Covering of point, plaster or other accessible materials containing dangerous levels of lead is to be provided
and must be received by the folioll-ing agencies, at least TEN (10 ) days prior io the beginning of deleading.
N0.TjjqCA-TY0NS 1 ckv RIC 1r,"x1l.
1. Department of Labor And WisrUorce Development, llivision of Geeupational Safety
399 NA ashinf on Street, 5" Floor, Boston, MA 0210E r4 (617) 727-756
2. Director, Cldidbood Lead Poisoning Prevention. Program
Dtpar•tment of Public Health, 470 Atlantic Ave., Boston, ll+kA 02111 FAX (617)753-8436
3. Occupants of dwelling unit
4. All Gill .Ar nreiipsntg of the residential premises, irAny
�.
Local Board of IfealtlzfCode EnforcementAgency
6, Massachusetts Historical Commission (if premises are listed on the State Register of -Historic
M) Morriasey iRlvd• .Places, tills notification must be made upon rPr.Pipt of ffn
Bustan, WUL 02202 Order to Co,Teet 11iolutions or at least 30 days prior to
FAX (617) 727-5126 iinitlating preventive deleading)
NO'II'1FICArioNS SHALL BE, COMPLETED Ili Tf-11EIP 1CNrTMETV', DATED AND S1GNE1) - MCOMI LETE NOTIFICATIONS
WILL NOT BE ACCEPTED AND WIL.L BE RETURNED BY THE, DEPARTMENT Ol! LAWOR & Womt'Ol-tC1J
IDV VFLOPMENT.
PROPERTY OWNER (If owner or ultliccnzed owner's agent will be Performing low -rill: dPl�pding u ori , CoMpkic the follt wiug)'
Property Owner_' Agents) _
Address
Telephone Number _L__).:
C
1ariifp that 1 have complied with the training requilmems of the t flni(mOn%"
105 Ch4it�161]_375, tnr nv�� /
alii1 Of Massachusetts tread Poisoning Prevcntior, and C nntroi RsaulntioPa,.
Agent 1ptCr-n8k Glauleiucgt trod coxitahancn4 Y t oicr ceiiiiy Wat 1 or my &gent Will be Performing the lou -ris3
following
activillce >: - � ;i .
(1 have, circled all that ap'ply): " :i
applying liquid ancapsulaut Capping baseboards renioti ing doors, cabinet doors, &butters
Applying exterior vinyl aiding wavering snrlace6
I mrti6k Ilrat all 11z1� information contained in this notification is hme arui correct to the best ot'my>asowledge and belief,
IAate Signed
t /y9 '
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