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NUMMIPWR TO A'V=W AMW ORAN*D
(\_ CITY OF SALEM
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(Ckola W*mwr apply) JW Raoof, ImW 80% COMM Dock, Shad, Pool
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PLEASE PILL OIR LAAMY&OOMPLUKY TO AVOW DM AYS M PROOEiN10
TO THE INBPECiOR OF B"NOS: '
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TM PNIALTY'
Of PONAMY
oEBCRfPraN OF Womc TO BE ooNE
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CrrY OF SALEM
BUIMING DEPARTMENr
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HONCOWM'S SIGNATURE
APPROVAL OF B=ING 1NSPECTOlt
Sa otba side for sate code
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HOMEOWNER'S EXEmMMON
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PUaUG PROPERTY-DEPARTMENT
;,+ 1 ZO VW1aMiNQrOR snlaaT aRD FLOOR '
"LEK MA Ot Y70
TFA-(979)748-MM MIT.a!O
FAX (Y78)740400"
STANLLYMJ�TIMOVICZ,JR:. --- -- " — -_ -- -
OR
DISPOSAL OF DEBRIS AFFIDAVIT
In ucordmce wills the paoviaim of MM c 4%SK I aclmoo WP that as a cmdidm
of Bm'ld*Pamir f 182 debris:resulting from the cma> nctiam a dit
Pvaaed by this BuDdmg Permit"be disposal of is a psoper>yr Hcemmd wH wnw
SelbtY*as dewed by MCL c Iq SISM
The debab wM be&pond of at M a P ^441 P(Aa:A M
locmdom�F
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uft
SiPNWm of ami<AWHcW DmW
May UUM��Latino:
Name of Permit Applicant
Firm Namq,if my
Addiesk city dt state - - - - —
'lbe above statute requires that debris from the dmsohtim rmmdwn,rehab or odw
d kradm ofba&ft or struCWm be disposed in A properly-Nomad solid-waste&Vwal
facility m defiaed by MGi,clM S1SOA,and the bulidins pbrmiot or licoma are to
indicate the locatlam of"fsrsWy.