HomeMy WebLinkAboutDe-Leading Notification - Miscellaneous - 12 FERRY STREET 3/2/2020 Department of Public Health-Childhood Lead Poisoning Prevention Prof
Deleading Noufleation
Phase complete an sections of this form clearly.Incomplete or MOW forma will be returned.
Lmd Faint� � s S
ah License#-ZY--ZO— inspection Data/P-.26`!9
Property Owaer �dar� ` z 6-)9
PropcttY Owner's Address �r !: red o v� Zip Code 0/$�1
Authorimd pin p"arming work: Ah� f vu r�L
Addreasofauthorixed Lic#/AudL#�1) -OM
Telephone Number /� ar °v r Zip Code ,5 / /�
Address where the want will be done:
Building
ut 'tom 8 (if my) Floor /�7'
Apt No. —
De { Zip a-�6- The Pro"is a multi family_X single faml[y.
o � t rk(��? 3 Dipping v Applying vinyl siding on exterior
p � JC Matting p�intact(m oderue Cap��removal(low risk
amponeat ramovai/rcplaeement Litlnid e9ularit
C A COV"S 0 Other
The work will begin on 2 /lI/20and will finish by 2/,a/�d no work will be done in the�
_pm or J�weelcends.
Incase of l3rnorgoncy Contsc t fa/�
Daytime Phone �Q
` o Evoaing Phone v f 9^7707
The Property Owner mast comp and alp the foHmWng iaformadon:
l certify 1119 only authorized persons who hate complied with the 01h tng mquhm mb of the MateachusMs Lead Poisoning Frovwdoni and
Control Rcgulations,105 CMR 460.000,will conduct deleading work i fiu'ther oa*Hutt the autltarized
nfhisAar authorhy and will be performing only those activities indicated abort.Ail of theinfiatmatioa persatt(s)will not exceed ilte scope
cormct to the best of my knowledge and belie£ In this docnm=is true and
Date Signed
The f6$owl89�PWQ90Rcecs must be notiiled tea drys before �worju
l. Occupants of the dwelling unit
. All other occupants of the residential premises,if any work Will be dace in the anmmaa areas
I Childhood bead Poisonins Prevention program,DP13
MWRHO Fax(781)774-6700
5 Randolph Street,Canton,MA 02021
4. Asbestos and Lead program,DLS
19 Sta dfard St, la Floor,Boston,MA 02114 SUBMIT Online
5. Local Board of HealthlCode Eng reemew Agency
*if the home is on the State Reg;ster of Historic Places,call the MA Hk torical Commission at(617)727-8470.