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CITY OF SALEM
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PUIM P"Off U�V A COMPLif ILLY TO AV=OBI "M PIIOf!/�10
TO TW INSPECTOR OF BUILDNM-
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OF PW&AWT
012cm110N OF MIOIMI TO BE 001E !!--
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PUSUO PROPERTY DEPARTMENT
' a20 WASHINQTON STftWM, aRDFLooR
SALaM,MA Oi Y7o
TEL (E79)745-9525 EXT.380
FAx (07e)74046"
STANLEY J. USOVK2, JR.,
MAYOR
DISPOSAL OF DEBRIS AFFIDAVIT
In accordance with the provisions of M(33,c 40,334,I as lmowledge that as a ca &den
of Bmlding Permit d .all debris resulting fmm the Esau* m Spyty
Soverned by this Buildiqg Permit shall be daapoaed of is a paoPerly licensed soH&waata
disposal facility,as ddhW by M(3L c Ill(,SISOA.
Tie debris will be disposed of at n)n/1,)a c 2 r
Location of Facility
r sae or remrit Appliaot Date
(PLEASE PRINT CLEAR
�A 3 e-l. . F LeALA^),c
Name of Permit Applicant
F$m Name,if say
�l b sl•�Z nr�r-� s� r�r�2. 1-0 � � /t�.�Addmm,City State o 19,s
The above statute regains that debris from the demohtioq naovMUM rehab or other
alteration of bm' ft or sir wmm be disposed is a propaly-licamW solid wsate&Woal
fuzzlity as defined by MGL cIII, S I30A, and the building permits or license:are to
indicate the location of the facility.
.f Costnlosuo of
rT •17aPaalwae(.�.�.�rc�t�{�ocilieb'
boo And
Worked' Competwdn Immanog AffMWk
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do berety'C?* under SIM PAN sad pagUm d pwjsWg dM '
1 am an ampi.@M wo g + orkeraa esa pmaadw covapts for aq siaplos w werift w
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liusennae Campeaw psaw Umber
1 aaa m aob peoples" and haw NO
oaas wer"M fdr ass in MW aMeb-
p i am• mile oreprieesr, general ceaeraerw or homeowner (drds am) and bum lied do
cocltraetoa Ilea/ below vvho hevo thi fopowitlg workers' Vo�dees
irooraais Gonital1P
Conorsovor
Coatraeaer Issuance Compawp/ o N
MAW
Conasaor laausau Cosnpsary/ iitaabor
() I am a homeowner performing ell the work myself.
•1.waow.e sea a GM of 06 alalaas We 11 ABFWWM a ON ON"A 1wawP M d eft aM M tws a1 J i1 a okodw e 'na 6
mam w M abler w r
comap at a~Inaba 21A a/WA 112 eaa iaae elf bemdaa d a6ohm eaara ewaM1
Waal :.ar..warw a ya a err aaUW w dw wm a!a STOP WORK MOM ow a ar 01 1100A0 a OR 000 s
Si this ._ day of
.' rseei'Fcnnne a bullacng Gepsrtn.ene
�jctnsing Eearl-
Sekesm m Office
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