0039 1/2 MASON ST - BPA-07-291 fL11fg M"jr.KfM:EB4ND APPROVED BY T44E
Jlh{SP==PRIOR WA PERMIT BEING GRANTED
CITY OF_SALEM
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BUHJXNG PEW APPLICATION FOR:
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EASE FILL OUT LEGIBLY i COMPLETELY TO DELAYS IN PROCESSING
TO THE WSPECTOR OF BUILDINGS:
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SWNED UNDE E ENALTY
OR PERJURY
DESC WrWN OF WORK TO BE DONE
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AppLICATION FOR
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LOCATION
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PERMIT
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INSPECTOR OF SUILDINGS
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Boston,MA 02111
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of up to$250.00 a day apaimt
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Coataet persons
CITY OF SALEM, MASSACHUSETTS
PUBLIC PROPERTY DEPARTMENT
120 WASHINGTON STREET. 3RO FLOOR
SALEM, MASSACHUSETTS 01970
STANLEY J. Ul avocz, Jot. TELEPHONE: 978-745-9595 EXT. 380
MAYOR FAX: 978-740-9846
Salem Building Department
Debris Disposal Form
In accordance with the provisions of MGL c40 S 54, a condition of your
Building Permit is that the debris resulting from this work shall be disposed
of in a properly licensed solid waste disposal facility as defined by MGL
Chapter III, S 150 A.
The debris will be disposed of in: 9EW Ei-l6ZAND sOGI� LJASrF� I Ale.
12OWGA-Y A. (Location of Facility)
Signa a of A
Date