Application for Permit to Engage in Exterior Paint Removal

DATE ISSUED

EXPIRATION DATE

APPLICANT: Please complete the following information

Property Located At

Owner's Name

Residence Address of Owner (if different than above)

Owner's Telephone Number

Contractor, Agent or Name of Person Who Will Perform the Paint Removal

Contractor or Agent's Address

Contractor or Agent's Telephone Number

Please Describe the Type of Exterior Removal to be Performed

Please Describe the Cleanup Procedures

I have read the Board of Health "Rules and Regulations for Exterior Paint Removal and Abrasive Blasting." I have had the opportunity to ask questions regarding those Rules and Regulations. I understand the Rules and Regulations and agree to abide by them and understand that failure to do so may result in fines pursuant to MGL c.62 s49A. I further certify under the penalties of perjury that I, to the best of my knowledge and belief, have filed all State tax returns and paid all State taxes required under law.

Print/Type Name

Signature

Please attach a photocopy of the applicant's photo ID.

For Board of Health Use Only

Approved By

Date Permit Issued

Permit #