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Sec other side for sale Code
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HOWOWNER'S SIGNATURE ,' + ,• ;r
APPROVAL OF BVIIDING WSPECTOA
Sa ada side im sm Code
CITY OF SALEM9, MASSACHUSETTS
j PUBLIC PROPERTY DEPARTMENT
120 WASHINGTON STREET, 3RD FLOOR
SALEM, MA O1970
TEL. (978)745-9595 EXT. 380
40 FAX (978) 740-9846
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# 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: tlo r}'h S i d e Car 4 i n G
/ /J Location of Facility
kd ��f_ Lee��rvca. 5'/6
Signature of Permit Applicant Date
FULLY complete the following information:
(PLEASE PRINT CLEARLY)
Rarbara Yh l912ci no�4,
Name of Permit Applicant
Firm Name,if any
� arndi e sf .Salekn., 1l4 oif7a
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 c1II, S150A, and the building permits or licenses are to
indicate the location of the facility.