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Home My WebLink AboutDeleading Notification Sep 29 2023 10:31am WILLIAM W. SANFORD 7743530340 p.1 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. ii Lead Paint Inspector ` � rifiRg,is License#3 �Z Insect 2 t — 2 , o Propertyl Inspection Date p�7��J Owner Sli'� 4 Kali e rA l,,5 nj Property Owner's Addreis3a Akin) HILL_ p„p egeosMI_ / 1 Zip Code �c1 t� / Authorized person performing work: '�,L•f3•? P Address of authorized person �0�0 Lic#/Auth.# a) 21 M 4 Zip Code Q ? Telephone Number[ --d() � Address where the work will be done:, Building Name(if any) Ot (s Py-_ 40 Floor .geH/✓�.1� n'''/ T �aZ) Street Address /g c-457,ve;2g4_, iitz-olii9,y gp Apt No. OG /iQ CityS, y I p VT ti Zip Code 06?6.6 The property is a multi-family V single family. Deleading Method(s): ❑ Making paint intact(high risk) a Making paint intact(moderate Applying Ying vinyl siding on exterior ❑ Demolition risk) Vo PP 0 Scraping Component removal(low risk ❑ Liquid encapsulant components) U Component removaUreplacement 0 Covering m o Other'o Dipping g a Capping baseboards The work will begin on// a3and will finish by? Ai-3. The work will be done in the ✓ am _pm or weekends. In Case of Emergenc ontact S . h sa g•iC K Daytime Phone 7 7o2a f Evening Phone 7 l --7�(2 —//`JZ 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 containedt in this document is true and orrect to the best f my knowledge and belief. J Date q lI I Signe The following people/agencies must be notified ten days 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,DPI-I MWRHO Fax (781)774 6700 5 Randolph Street, Canton, MA 0202 i 4. Asbestos and Lead Program, DLS 19 Staniford St, 1"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. Oct 06 2023 12:29pm WILLIAM'W. SANFORD 7743530340 p.1 Depailuient 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 kli-p Pi (Lt .f License# j Inspection Date ?c)(;-c:32 Property Owner A- n C• so o 1� Property Owner's Address im 1d p 1) 'di (Ss-et,'Sbr) N1A Zip Code ( b3 1 Authorized person performing work: W 1 I.1 I cA t Lic#/Auth.# 356 g '/ L Address of authorized person -3 2 Pu— K e-Lei I jr nN\ Zip Code Telephone Number(-0,-1a 6 Y . 1 �� Address where the work will be`'d�n,e: Building Name(if any) vim►�i.' 1 I ci f h Floor ey(-{-+,r)or SAtri Street Address ) <$ 6e n er eA,1 UI La) - 124_S.V/. Apt No. CityCitYa_crADLE11.71%Zip Code Cat, The property is a multi-family /10 single family. Deleading Method(s): ❑ Making paint intact(high risk) ❑ Making paint intact(moderate ❑ Applying vinyl siding on exterior ❑ Demolition risk) ( Component removal (low risk ❑ Scraping ❑ Liquid encapsulant components) 0 Component removal/replacement 0 Covering o Other: ❑ Dipping ❑ Capping baseboards The work will begin on(n/�/.�3nd will finish byOs/ /a3The work will be done in the V.-am pm or weekends. In Case of Emergency Contact Ste:,pkekn En de S L11 Daytime Phone `)-)/ --/z 2_-1 fr.)( Evening Phone' t-f- -72 2"-//or 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 d my knowledge and belief. Date [ Si The following people/agencies must be notified ten days 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 MWRIIO S Randolph Street, Canton, MA 02021 4. Asbestos and Lead Program,DLS 19 Staniford St, 151 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.