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Department of Public Health & Department of Labor
Id I y)i=p, II'9� N'OHFICATION OF DELEADINC WORK
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t +, V1 I All sections of this form must be completed in order to comply with
x4' the notification requirements of NI.G.L. C. I11§197,
454 C -NIR 22.00 and 105 C'11R 460.000, as most recentiv amended
Contractor performing project AUISOn Roofing, Inc. License # DC001523 Esp. Date 04/02/15
Lead Paint Inspector Dennis Daly Date of Inspection 10/30/14
.ADDRESS OF PROJECT:
Street Address 62 Forrester Street
Cita Salem
Property Owner SL Nicholas Russian Orthodox Greek Catholic Church address
Telephone Number (781-799-5590
Deleading Method:❑ Wet/Dry Scraping ❑ Heat Gun
❑Demolition ❑ Caustics
(DCovering, ❑ Other
If "Other" selected. please explain
License # M-1908 Exp. Date 06/02/15
Units 1, 2 & 3
01970
64 Forrester St., Salem, MA 01970
❑ Liquid Encapsulant
0 Replacement
Check one: Dwelling is multi -family -F-71 Single-family= Other
Start Date 12/12/14 Completion Date 12/30/14
When will work be done: ANI 8 P\I 4 (Specify times on site) Weekends? NO
Project Supervisor Name Gary Eap License # DS003310 Exp. Date08/21/15
Worker's Compensation Policy Number WC0686323 Carrier Star Insurance Company
In case of emergency contact Scott AUlson Tel, #_9( 78 ) 423-3472
(Contractor's Representative)
DELEADING CONTRACTOR
The undersigned hereby states, under the pains and penalties of perjury, that he/she has read and understood the Commonwealth of
Massachusetts Deleading Regulations, 454 C)IR 22.00, and the Lead Poisoning Pr vention and Control Regulations. 105 CNIR 460.000, and
that the information contained in this notification is true and correct to the bes_ f hiss/yr know ledgf,�pd b>e]" I
Date December 2, 2014
Company Name AULSON ROOFING, INC.
.Address 49 DANTON DRIVE, METHUEN, MA 01844
Telephone Number (978) 975-4500
OVER4
y. J
Cathy Ginas
From: DoNotReply@dos.state. ma. us
Sent: Tuesday, December 02, 2014 2:44 PM
To: cginas@aulson.com
Cc: rsbeaman@comcast.net
Subject: DELEADING NOTIFICATION FORM DELEADING CONTRACTOR
Thank you for submitting your Deleading Notification Form DELEADING CONTRACTOR, Please retain
this email for your records.
Confirmation #: 3049087
Submission Date: 12/02/2014 02:44 PM
NOTIFICATION OF DELEADING WORK
The Notification is: Routine Notification
DLS Waiver Number:
House Number: 62
Street Name
Street Type
Forrester Street
St
Unit/Apt Number
City: Salem
1, 2&3
1
Zip Code: 01970
Property Owner/Agent: St. Nicholas Russian Orthodox Greek Church
Phone :781-799-5590
Owner Address: 64 Forrester St., Salem, MA 01970
Email: rsbeaman@comcast.net
Name of Licensed Lead Inspector/Risk: Dennis Daly
Inspector/Risk Assessor License Number: M-1908
Date of Inspection: 10/30/14
Expiration Date: 06/02/15
CONTRACTOR INFORMATION
Contractor Name: Aulson Roofing, Inc.
Contractor Address: 49 Danton Drive
City: Methuen
z
i
State MA
Zip Code: 01844
Contractor Contact Person: Aulson Roofing, Inc.
Office Phone: 978-975-4500
Cell Phone: 978-423-3472
Email: cginas@aulson.com
Contractor License Number: DC
Six digit Number: 001523
Expiration Date: 04/02/15
LR/LW Name:
License/Authorization Number : MR
DS/MR six digit Number:
Expiration Date:
TYPE OF DELEADING WORK TO BE PERFORMED:
Class I Deleading Methods Selected
9
Covering,Making Intact,Replacement,Wet/Dry scraping or wire brushing,
Moderate Risk Deleading Methods Selected:
Liquid Encapsulation,
Low Risk Deleading Methods Selected:
N/A,
0181 :WOM411AIi
Project Start Date: 12/12/14
Project Completion Date: 12/30/14
Project Start time: 8 am
Project End Time: 4 pm
End of email
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