Free Lead-Free Inspection Affidavit of Property Owner, DPH 44014 - Wisconsin

DEPARTMENT OF HEALTH AND FAMILY SERVICES Division of Public Health DPH 44014 (04/02)

STATE OF WISCONSIN Bureau of Occupational Health HFS 163, Wis. Adm. Code (608) 261-6876

LEAD-FREE INSPECTION AFFIDAVIT OF PROPERTY OWNER
Read instructions below before completing this form.

This affidavit is to be completed if in the last 12 months any of these apply: · no paint was removed or disturbed while a component was removed, · less than 2 square feet of paint was removed, or · less than 2 square feet of paint was disturbed in removing a component*. This affidavit is to be signed by the property owner, employee, or the property owner's agent. If more than 2 square feet of paint was removed or more than 2 square feet of paint was disturbed in removing a component, then the property owner will provide a clearance report or the work area will be included in a clearance portion of the lead-free inspection. The lead company is to keep this affidavit on file as part of the lead-free inspection report. This affidavit must be available to the Department of Health and Family Services upon request. * "Component" means a specific design, architectural or structural element or fixture of a structure that is distinguished from another component by form, function or location. Interior components include ceiling, crown molding, wall, chair rail, door, door trim, floor, fireplace, radiator or other heating unit, shelf, shelf support, stair tread, stair riser, stair stringer, newel post, railing cap, balustrade, window and trim (including sash, window head, jamb, interior sill or stool and trough), built-in cabinet, column, beam, bathroom vanity, counter top and air conditioner. Exterior components include painted roofing, chimney, flashing, gutter, downspout, ceiling, soffit, fascia, rake board, cornerboard, bulkhead, door and door trim, fence, floor, joist, lattice work, railing, railing cap, siding, handrail, stair riser, stair tread, stair stringer, column, balustrade, exterior windowsill, window trough or well, casing, sash and air conditioner [s. HFS 163.03(17), Wis. Adm. Code]. PROPERTY DESCRIPTION Street Address City Common Area Description I state that I am the property owner, employee, or property owner's agent for the property described on this form. I have no notice or knowledge of any person, during the previous 12 months, removing a total of more than 2 square feet of paint or disturbing more than 2 square feet of paint when removing a painted component from the real property included in this lead-free inspection. I understand that false or forged statements made in connection with this form may be grounds for denying or revoking any certificate issued for the described property or for other disciplinary or legal action. I also understand that if I am issued a certificate, failure to comply with the laws or rules of the State of Wisconsin may be cause for disciplinary or legal action.
Check Relationship of Signee to Described Property Property Owner Employee Property Owner's Agent

Unit(s) State Zip + 4

Print Name of Signee

( ) Telephone Number of Signee

SIGNATURE ­ Property Owner, Employee, or Property Owner's Agent,

Date Signed (mm/dd/yy)