Laserfiche WebLink
Erie Home <br /> Lead-Based Paint Renovation,Repair,and Painting Form <br /> Customer Name: <br /> Customer Address: _ <br /> City: _ State:. zip Code: <br /> The purpose of this form is to determine if the proposed home renovation is,or is not,exempt from the Environmental Protection Agency guidelines <br /> and requirements for Lead Safe Work Practices. <br /> occupant Confirmation of Pamphlet Receipt <br /> 0 By checking this box,I acknowledge that I have received a copy of the pamphlet"The Lead-Safe Certified Guide to Renovate Righf informing <br /> me of the potential risk of the lead hazard exposure from renovation activity to be performed in my dwelling unit I received this pamphlet before work <br /> began. <br /> Qualified Exemptions-Homes Built After 1977 <br /> To exempt the property as post 1977 housing,both options below shall be completed: <br /> (A)The contractor shall verify prior to commencement of work,through an independent third party(such as assessor records, <br /> housagecheck.com,Zllow.com,etc.)that the house on which the work will be performed was constructed during or after 1978.Proof of this <br /> verification shall be obtained prior to commencement of work through available public records. <br /> AND <br /> ❑ (B)The customer also agrees that to the best of their knowledge,the property where the work will be performed was built after 1977. <br /> Customer Initials Customer Initials <br /> ❑ (C)I agree that due to the above exemption(s),the firm will not be required to use lead-safe work practices as outlined by the EPA's <br /> Lead-Based Paint Renovation,Repair,and Painting Rule. <br /> OR(Non-Exempt Homes Built before 1977) <br /> RI (D)I understand that the firm performing the renovation is going to follow the work practices outlined in the EPKs Lead-Based Paint Renovation, <br /> Repair,and Painting Rules.I also understand that a portion of the contract price as identified may be associated with the cost of following these <br /> guidelines. <br /> Customer Signature Printed Name Date <br /> Customer Signature Printed Name Date <br /> Contractor's Representative.I certify under penalty of law that the above information is true and complete to the best of my knowledge. <br /> i2em) _�4 �� POL4 S 4Lo�_ <br /> Contractor Representative Signature Printed Name Date <br /> White—Contractor Yellow—Customer <br /> LSWP2 2/22 <br />