HomeMy WebLinkAboutDeleading Notification - Miscellaneous - 52 BUCKINGHAM ROAD 5/27/2022 Department of Public Health-Childhood Lead Poisoning Prevention Program
Deleading Notification
Please complete all sections of this form clearly.Incomplete or illegible forms will be returned.
Lead Paint Inspector ¢�V y C License#rn loa,�Inspection Date 1( •
Property Owner A t--I rJ C M E/e4C.C-A W
Property Owner's Address Z �� 5� �4 n!�h 1-Zip Code
Authorized person performing work: Imo} Lic#/Auth.#
Address of authorized person0. Zip Code
Telephone Number
Address where the work will be done:
Building Name(if any i Floor
Street.Address S'—Z- U-ANV% 0!3 Apt No.
City coil-#i$nJ t�,N& Zip Code 61 g� The property is a multi-family single family.
Deleadint!Method(s):
❑ Making paint intact(high risk) -W Making paint intact(moderate ❑ Applying vinyl siding on exterior
❑ Demolition risk) )r Component removal(low risk
❑ Scraping 2d Liquid encapsulant components)
U Component removal/replacement V, Covering ❑ Other:
❑ Dipping ❑ Capping baseboards
The work will begin on la a/2;and will finish by 8/3 1/22-The work will be done in the A amxpm or)weekends.
In Case of Emergency Contact i
Daytime Phone [Q G 5`-Jp V2_1 92 Evening Phone
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 c ect to the st y knowledge and belief.
Date-5 -2Z- 22-- Signed ti0tiI JER
The following people/agencies must be notified ten days before beginning work: * Mph PqN PAP iz�
1. Occupants of the dwelling unit 1013��NP�
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 Street, Canton, MA 02021
4_ Asbestos and Lead Program,DLS
19 Staniford St, I'Floor,Boston,MA 02114 Fax(617)626-6965
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.