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CITY OF SALEM9 MASSACHUSETTS
PUBLIC PROPERTY DEPARTMENT
120 WASHINGTON STREET, 3RD FLOOR
SALEM, MA O1970
( TEL (978)745-9595 EXT. 380
FAX (978) 740-9646
STANLEY J. USOVICZ, JR.
MAYOR
DISPOSAL OF DEBRIS AFFIDAVIT
In accordance with the provisions of MGL c 40, S34,I acimowledge that as a condition
of Building Permit 0 .all debris resulting from the construction activity
governed by this Building Permit shall be disposed of in a properly licensed solid-waste
disposal facility.as defined by MGL c III,S150A
The debris will be disposed of at: A "IL,S� ) o e
Location of Facility
Signature of P i plicant Date
FULLY complete the following information:
(PLEASE PRINT CLEARLY)
T
o� vs'
Name of Permit Applicant
Firm Name,if any
/
Address.City& State
The above statute requires that debris from the demolition,renovation,rehab or other
alteration of building or structure be disposed in a properly-licensed solid-waste disposal
facility as defined by MGL ca S 150A, and the building permits or licenses are to
indicate the location of the facility.