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2^nd Story Construction, Inc.

2106 Pacific St. #101

Bellingham, WA 98229

(360)-734-1515

Renovator Disclosure Rule

Lead-Based Paint and / or Lead-Based Paint Hazards

Fill in one of the options below.  You  may attach form to work contract.  Maintain this form for three years.

OPTION 1 - OCCUPANT ACKNOWLEDGEMENT STATEMENT

I have received a copy of the pamphlet.  Protect Your Family From Lead In Your Home,    informing me of the potential risk of lead hazard exposure in my dwelling unit. I received this pamphlet before the work began.

Printed Name:____________________________________________________________

Signature:_____________________________ Date:______________________________

Address of unit Undergoing Renovation:_______________________________________

OPTION 2 - RENOVATOR’S CERTIFICATION OF DELIVERY

I certify that I have made a good faith effort to deliver the pamphlet, Protect Your Family From Lead In The Home, to the unit listed below at the dates and times indicated, and that the occupant refused to sign the acknowledgment or was unavailable to sign the acknowledgment.  I further certify that I left a copy of the pamphlet at the unit by sliding it under the door or by other means indicated below.

Name of renovator or designated representative who delivered pamphlet:_______________.

Address of the unit undergoing renovation:______________________________________.

Date(s),Time(s), and Method of attempted delivery: _______________________________.

Date, Time, and Method of Actual Delivery: _____________________________________.

Reason for lack of Acknowledgement by Occupant: (Check one)

____Occupant Unavailable

____Occupant Refused to Sign

Signature of Renovator or Designated Representative:_____________________________.

Date of Signature:_________________________________________________________.

OPTION 3 - SELF CERTIFICATION OF MAILING

I hereby certify that I mailed a copy of the pamphlet , Protect Your Family From Lead In Your Home, to the unit listed below at least 7 days prior to the start of the renovation of the unit.  I have attached a certificate of mailing (or other proof of mailing such as registered mail receipt or certified mail receipt) to this form.

Signature of Renovator:______________________________________________________.

Date of Signature: __________________________________________________________.

Address of Unit Undergoing Renovation:________________________________________.