Department of Labor Standards
 19 Staniford Street, 2nd Floor
 Boston, MA 02114
 www.mass.gov/dols
 Department of Public Health
 Childhood Lead Poisoning Prevention Program
 Donovan Health Building
 5 Randolph Street
 Canton, MA 02021
 www.mass.gov/dph/clppp
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 s 197, 454 CMR 22.00 and 105 CMR 460.000, as most recently amended.
   This Notification is    
NOTIFICATIONS MUST BE SIGNED, DATED AND COMPLETED IN THEIR ENTIRETY. INCOMPLETE NOTIFICATIONS WILL NOT BE ACCEPTED.

   Project Information : A proper address is critical. All addresses must be verified through the USPS database Address Verification

   House Number:    Street Name:
   Street Type    Unit/Apt Number:
   City:    Zip Code:

   Property Owner/Agent:    Phone:  
   Owner Address:    Email:
   TYPE OF DWELLING:

   Second Property Owner/Agent:    Phone 2:
   Owner Address 2    Email address 2:
   TYPE OF DWELLING 2:

   Inspection Information: Before starting any work, contractors should check a property's previous lead inspection history at CLPPP Lead Inspected Homes Database

   Name of Licensed Lead Inspector/Risk:
   Inspector/Risk Assessor License Number:
   
   Date of Inspection:           Date of Expiration:   

   DELEADING CONTRACTORS AND MODERATE RISK SUPERVISORS PERFORMING DELEADING WORK:

   PROPERTY OWNERS AND/OR OWNER'S AGENTS PERFOMING LOW OR MODERATE RISK DELEADING WORK ON THEIR OWN PROPERTY: