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APPLICATION P�
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LOCATION
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PEFWAT GRANTED
APP OVP
OF OPLOPM
CITY OF SALEM, MASSACHUSETTS
PUBLIC PROPERTY DEPARTMENT
120 WASHINGTON STREET, 3RD FLOOR
SALEM, MA O1970
TES. (976)745-9595 EXT. 380
so 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: Dyo
Location of Facility
S-7z-y
Signature of Permit Applicant Date
FULLY complete the following information:
(PLEASE PRINT CLEARLY)
D61� J ISvr.'�
Name of Permit Applicant
Firm Name,if any
(( �-'G (I Sr o l4 ?0 .
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 cR S 150A, and the building permits or licenses are to
indicate the location of the facility.
CITY OF SALEM
BuiLziNG DEPARTmM
B01aOVI M LICENSEE monoN
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HOMEOWM
PRESENT MARNO ADDRM
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DEFIIWION OF HO NEOWNM
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HOMEOWNER'S SIGNATURE
APPROVAL OF B=ING DWECrCR
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See Ww side fm sate code
CITY OF SALEM
BU MING DEPANTMW
liMaOW NEIL LICENSE E)m&noN
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HOMEOWNER'S SIGNATURE
APPROVAL OF BIMDING U;MCfOR
Sec ww ode for sate code