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DEPARTMENT OF PUBLIC HEALTH/DEPARTMENT OF LABOR & INDUST .
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, SECTION 197
FILE NUMBER
CONTRACTOR PERFORMING PROJECT: LcAr)( moll��- AW2,mj0 ',ts
CERTIFICATION # DL065631 LEAD PAINT INSPECTOR PANII113 ip(a(da„
DATE OF INSPECTION 9 Z,
ADDRESS OF PROJECT
BUILDING NAME SIF ANY) FLOOR 1 -2-
STREET
"-zSTREET ADDRESS 5 Wood , LA Ne._ APT, N0 , ---
CITY QE)- Ayld0✓-er mi� ZIP 018y5
DELEADING METHOD DRY SCRAPING HEAT GUN E APSULATION
(CIRCLE ALL THAT APPLY) DEMOLITION POWER SANDING RUSTIC
REPLACEMENT OTHER
IF "OTHER" SELECTED, PLEASE EXPLAIN
CHECK ONE DWELLING IS : MULTI FAMILY SINGLE FAMILY
START DATE 512.5)Iiz- COMPLETION DATE � f 12-1 9Z-
WHEN WILL WORK BE DONE? A . M. 7. 30 P . M. Ll-'5d WEEKENDS
PROJECT SUPERVISOR NAME Tohn P"• Nonr- - CERTIFICATE # DSJ60�
PROPERTY OWNER ( rUS k- s r�-r �e 5.2,E t141'�j1Nt S ��p To'r`2
ADDRESS 2-00 �� � �� 'I�pI,
CITY STATE f"l ZIP CODE 01 138
TEL LEP H0NE (So� 3 - y351
IN CASE OF EMERGENCY CONTACT : 76hn Dfaq �^--�-
TELEPHONE : DAYS CToa)!17? -91Lo EVENINGS C5 8) Z81--5SO y
I
IN ACCORDANCE WITH CHAPTER 773 OF THE ACTS OF 1987, MASSACHUSETTS
GENERAL LAWS C . 111 , SECTION 197, 454 CMR 22 , 00 AND 105 CMR 460. 00,
NOTICE OF THE DATE AND METHODS OF REMOVAL OR COVERING OF PAINT,
PLASTER SOIL OR OTHER A,CCESSI3LE MA.TERIAL CONT,' INING DANGEROUS LEVELS
OF LEAD, IS TO BE PROVIDED TO THE FOLLOWING PERSCNS AT LEAST FIVE DAYS
PRIOR TO THE BEGINNING OF DELEADII
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
SIF PREMISES IS LISTED ON THE STATE REGISTER OF HISTORIC PLACES) .
THE UNDERSIGNED HEREBY STATE, UNDER THE PENALTIES OF PERJURY, THAT
HE/SHE HAS READ AND UNDERSTOOD THE COMMONWEALTH OF MASSACHUSETTS
DELEADING REGULATION 454 CMR, 22 .00, AND LEAD POISONING PREVENTION AND
CONTROL REGULATIONS, 105 CMR 450 . 00, AND THAT THE INFORMATION
CONTAINED IN THIS NOTIFICATION IS TRUE AND CORRECT TO THE BEST OF
HIS/HER KNOWLEDGE AND BELIEF ,
DATE JJJl� SIGNED
TITLE "Pro 1•eCf
COMPANY UA0Q Mu Fly
----------------------------------------------------------------------
OFFICE USE ONLY
Town of North Andover,
Watershed Septic System
Servicing Regort --
Date:
Homeowner: Pumper ) ) p
StreetAddress:
Phone Phone
Nature of Service: Routine
I
Emergency
Observations: Good Condition
Full to Cover
Baffles in Place
Leachfield Runback
Excessive Solids
Heavy Grease
Roots
Other (Explain)
Description of Work:
Comments:
MASSACHUSETTS PROPERTY INSURANCE UNDERWRITING ASSOCIATION
Two Center Plaza
Boston,Massachusetts 02108.1904
(6171723-3800 Ma Only(8001392-6108,FAX(8001851.8424
3/23/2011
Form of Notice of Casualty Loss to Building
Under Mass.Gen,Laws,Ch.139,Sec.313
NORTH ANDOVER HEALTH DEPT.
NORTH ANDOVER TOWN HALL
NORTH ANDOVER MA 01845
Re: Insured: ISABEL M DELEON
Property Address: 5 112 WOODLAND STREET,N A 01a,Policy Number: 1130348 RE810 "
Type Loss: Ice Dams
Date of Loss: 0210112011 '!t1k
Claim Number: 287077 TOWN OF NORTH ANDOVER
HEALTH DEPARTMENT
Claim has been made involving loss,damage or destruction of the above captioned propert,which may either
exceed$1000.00 or cause Massachusetts General Laws,Chapter 143,section 6 to be applicable. If any
notice under Massachusetts General Laws Chapter 139,Section 313 is appropriate,please direct it to the
attention of the writer and include a reference to the captioned insured,location,policy number,date of loss
land claim or file number.
MPIUA Claims Division
CMA00021
08/05;2010 15:48 FAX 18787412012 A&ASERVICES 1@002/003
r
Department of Public Health&Department of Labor
NOTIFICATION OF DELEADING WORK
L �
All sections of this form must be completed In order to comply with
\ f the notification requirements of M.G.L.C.111§197,
454 CMR 22.00 and 105 CMR 460.000,ss most recently amended
Contractor performing project.Christopher ZOIZy _License# DC000440 Exp.Date 04/13/2011
Lead Paint c ori3iBlankman Date of Inspection 06/15/2010 License 4 M/R 13771Exp.Date
D
Str t Address 5 Woad Lane Apt.Number --_
city orth Andover, MA zip 01845
Property Owner Trustees Of Reservations Address 572 Essex Street, Beverly, MA 01915
Telephone Number 978.375-0579
Doloading Method:21Wet/Dry Scraping ❑Heat Gun []Liquid Encapsulant
❑Demolition El Caustics 0 Replacement
❑d Covering [3 Other
If"Other'selected,please explain
Cheep one: Dwelling is multi-family Single-family Other
Start Date AU9USt 23, 2010 Completion Date August 25, 2010
When will work be dome: AMX PM X (Specify times on site) Weekends?
Project Supervisor Name Willie W00dS License*DS003534 I,xp.Date 10/04/2010
Worker's Compensation PolicyNumbar 0243MB15UB Cnrrier Traveler's
In case of emergency contact Christopher Zorzy Tel,#_ 97( S 1 741-0424
(Contractor's Representative)
DELEADING CONTRACTOR
The undersigned hereby states,under the pains and penalties or perjury,that he/she has rend and understood the Commonwealth of
Massachusetts Deleading Regulations,454 CMR 22.00,and the Lead isoning Prevention and Control Regulations,105 CMR 460,000,and
that the Information contained in this notification is true and eorr t c best of his/her knowledge and belief.
Date Signed
Company Name A&A Services, Inc.
Address 115 North Street, Salem,MA 01970
Telephone Number 978-741-0424
OVER