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APPLICATION FOR
PEI TO
LOCATION
60 L4
PEFtWr GRANTED
OF OJL PM
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CITY OF SALEM,, MASSACHUSETTS
PUBLIC PROPERTY DEPARTMENT
120 WASHINGTON STREET, 3RD FLOOR
SALEM, MA O1970
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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 constriction 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.
`T BE BY
The debri ll be dispopA of at:
J Location of Facility
r
✓��7 0 J�
Si of Permit./Applicant Date
FULLY omplete the following information:
(PLEASE PRINT CLEARLY)
U %AAfI,sAltie4
Name of Permit Applicant
Firm Name,if any
llfl[tEy[ ST. fjgf Ina
Address,City &S
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 cIII, S150A, and the building permits or licenses are to
indicate the location of the facility.
CITY OF SALEM
BUIIDING DEPAILTNENr
HOUBOWNER UCENSE nEMQ 1zoN
Plan Pdat
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PRESENT1dAB.IIT.G ADORES: � (/iq-�[,Ey ST SftL� f�'/�3 /7/�97d
• The cwtent.ammpti0ti d'1 '*+a etaended to bichsk ew0et�plcd.dev�V�='W�
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occuse,.piovided daetbs owsw ad d
DEn IITICHCFHCMEOWNM
Pcn m O)Wbo owm s pool of WA a w Web bdsb&asides a bscads to tssi0q o!t"' lR .
intended m be,s one m two bvft dwd>i M smdad a&Nd d sttuetwa==my 1 SO& u MAAW
Wm d
m svocwm A pen=WbO mat Om m Om mg home k s two yesr p�
s homeowner. Suefi'Aomeow•ner sw n*nk w the Buadbs OlfxbL @s s bai .-age
Bwldh�Offio4 that UhM be uspomtbk to an swh w•ak in a ma Ore
The wwa ip a-bomeownet"asawm respomt MV fa compliatec wt&t n Stale BWMffi S Code od
other appliabk does by-kws,rnks sad nVAs iaL
•nt wAcysipud abomeownerecrti5o the Cid of
minimwo impeWm pmocdwe sad req Nshe wm mofv
agabsaeeeL � r
HONEOWM*S SIGNATURE � \
APPROVAL OF BUIIDING INbFECTOit
See mba ode fa tart code
QTY OF SALEM
BURWG DEPARTMOU
HOMEOWNER LICENSE EMOMON
Pkeae Fdd
DAZE
IpBLOCATION
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pnSiNT MAL.1NG ADORES=
The emrest.aacmpJoo wmeow r was camn"to bwb3&owoes aF�l 0 aT'�
d'9 o
Uwa a k�a and o afbw sa]t 1!omeowmm to wwr an mm vbo does not pones•
ikcare,,pawtdrd tda tde e�raer aee d .
DEmarmorHOMEOwsm
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Pea id d i bib owns a twat syadod a deudW taruenva aoo�os7 ti rue!M ae 'I
hrm s d to be,a am to two m rum m, aot be amddaad
farm strttcooa.A tersao wbo enrtsunets tnoee that one btone in a two•�a 1��Pw�to is
a bumoownet: Suer-hmeow•aet" sha><subrtdt m the BnildirK Olitdal.
Bm'idb g 0die4 that bcJdte be ngcw%k to all sods work pml' crowd
The tmdcmpad-bomeowner&wwm=90m%mv fa=Pon=wWh*A Staff Bnaft Code d
other ffgcmbk`ace W-kwt,ruka aced mpbdaL
The trod ..lpa -homww ne certifies that Wft tmdwsw&the ed
muu mo bdpccdm tmcsdma and requueatetnsandthat b/she wBl Wes'
rcqWnnm&
H0NWvj ER'S SIGNATURE
APPROVAL OF BIWING D;MCMR
See other sde for an code