Pre-Renovation Lead-Safe Form

Wilber's Home Improvements

Pre-Renovation Lead-Safe Form

Thank you for choosing Wilber’s. Please read, complete, and submit this form prior to your project start.

I have read the lead hazard information pamphlet via email (PDF) or in person from Wilber’s informing me of the potential risk of the lead hazard exposure from renovation activity to be performed in my dwelling unit. I received this pamphlet upon receipt of my estimate or before the work began.

Location/Address

Printed Name of Owner-occupant

Signature of Owner-occupant

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Date picker

Renovator’s Self-Certification Option

(for tenant-occupied dwellings only)

Instructions to Renovator: If the lead hazard information pamphlet was delivered in person but a tenant signature was not obtainable,

you may check the appropriate box below.

Declined— I certify that I have made a good faith effort to deliver the lead hazard information pamphlet to the rental dwelling unit listed above at the date and time indicated and that the occupant declined to sign the confirmation of receipt. I further certify that I have left a copy of the pamphlet at the unit with the occupant.

Unavailable for signature— I certify that I have made a good faith effort to deliver the lead hazard information pamphlet to the rental dwelling unit listed above and that the occupant was unavailable to sign the confirmation of receipt.

I further certify that I have left a copy of the pamphlet at the unit by sliding it under the door or by detailing below how the pamphlet was left.

Printed Name of Person Certifying Delivery

Issue Date

Signature

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Signature of Person Certifying Lead Pamphlet Delivery

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