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APPLICATION FOR
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LOCATION
PERIAT GRANTED
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CITY OF SALEM
BXMZING DEPARTMW
HONZOWNERLICENSEE menoN
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>�LOCATION
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HOMEOWNER'S SIGNATURE U
APPROVAL OF BUIIDING YMCTOR
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See otba side for stue code
C11 Y OF SALEM
BURZINGDEPARTiv M
HOMEOWNER LICENSE EMOMON
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HOt.OWM'S SIGNATURE
APPROVAL OF B=D4G 1NSPEC10it
Sec mba side for mu coda
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CITY OF SALEM� MASSACHUSETTS
PUBLIC PROPERTY DEPARTMENT
� � 120 WASHINGTON STREET, 3RD FLOOR
SALEM, MA O1970
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 aclmowledge 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, S150A.
The debris will be disposed of at:
O q LDoc'ation of Facility
(1./ _
Signature of Perffiit Applicant Date
FULLY complete the following information:
(PLEASE PRINT CLEARLY)
Name of Permit Applicant
Firm Name, if any
L3 woo�S�nd sr; SAwA4A07c)
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 cIII, S150A, and the building permits or licenses are to
indicate the location of the facility.