HomeMy WebLinkAboutCorrespondence - 44 SAUNDERS STREET 11/5/2015 Moderate Risk Owner/Agent Course Manual Course Developed By: RF.coverz
Environmental Training Institute Childhood Lead Poisoning Prevention Program
Department of Public Health- Childhood Lead Poisoning Prevention Program
Deleading Notification TOWN V NOR'rH ANDOVEF�
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Please complete all sections of this form clearly.Incomplete or illegible E ALTH DEPAR7
iegible forms will be returned. VENT
Lead Paint Inspector—M ar, License#3 1 L i Inspection Date
Property Owner 5�C VC
Property Owner's Address Zip Code 01 S•
Authorized person performing work: IV\
-;i--.L(N 1%<A v\,.Lic#/Auth.# Koo)�a,Jv
Address of authorized person 41-1 Zip Code..Qj_q
Telephone Number 0:�)
Address where the work will be done:
Building Name(if any) Floor Z
Street Address 46- Apt No. 7-
City h)"')Al vVtr -Zip Code 2,�I Ca, The property is a ulfi-family_single family.
DejeadinLMethoffsj.-
❑ Making paint intact(high ❑ Dipping ❑ Applying vinyl siding on
risk) ❑ Making paint intact exterior
w<Demolition (moderate risk) ❑ Component removal(low
❑ Scraping ❑ ,Liquid encapsulant risk components)
L3 Component Covermg ❑ Other:
removal/replacement Capping baseboards
The work will begin on t e /i/6'and will finish by)Z 57 The work be done in the -16m-�4m or weekends.
In Case of Emergency Contact C V 4 1w ire^ �
Daytime Phone 11-7 6 1 s T) S Evening Phone -17 r 3 6 1 S-)�S-
'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 correct to the best of yknowledge and belief.
Date i, Signed
The following people/agencies must be notified before beginning work:
1. Occupants of the dwelling unit
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
5 Randolph St,Canton,MA 02021
4. Asbestos and Lead Program,DOS
19 Staniford St, I'Floor,Boston,MA 02114 Fax(617)626-6965
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.
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