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CITY OF SALEMV MASSACHUSETTS
♦ PUBLIC PROPERTY DEPARTMENT
IZO WASHINGTON STREET, 3RO FLOOR
SALEM,MA O 1970
TEL. (976)745-9595 EXT. 360
40 FAX (976) 740-9646
STANLEY J. UVIOVICZ, 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 chili be disposed of in a properly licensed solid-waste
disposal facility, as defined by MGL c III,S150A.
The debris will be disposed of at 4 �: h
Location of Facility
Sigoanu of Permit Applicant Date
FULLY complete flu following information
(PLEASE PRINT CLEARLY)
�el7h�.Y</ �eM e r`nS
Name of Permit Applicant
Firm Name,if any
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 w defined by MGL cIII, S 150A, and the building permits or liceasea are to
indicate the location of the facility.