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HOMWWMI SIGHATURE
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a CITY OF SALEMI, MASSACHUSETTS
PUBLIC PROPERTY DEPARTMENT
120 WASHINGTON STREET, 3RD FLOOR
SALEM, MA O 1970
TEL. (978)745-9595 EXT. 380
FAX (978) 740-9846
STANLEY J. USOVICZ, JR.
MAYOR
DISPOSAL OF DEBRIS AFFIDAVIT
In accordance with the provisions of MGL c 40, S34,I acknowledge that as a condition
of Building Permit# . _ 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, S 150A.
The debris will be disposed of at:
Location of acility
ture of Penmit phc Date
FULLY complete the following information:
(PLEASE PRINT CLEARLY)
e Ir \
Name of Permit Applicant
Firm Name,if any
Addres , 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 cM, S150A, and the building permits or licenses are to
indicate the location of the facility.