DEMO PERMIT SIGN-OFF CITY OF S.,U EN4 (MASSACHUSETTS
• BuUMNG DEP kRT1tEINT
j 130 WASHINGTON STREET,3w FLOOR
TEL (978) 745-9595
FAx(978) 740-9846
KI.\iBERLEY DRISCOLL
MAYOR T Hoaus ST.PIERRe
DIRECTOR OF KBUC PROPERTY/BUUMNG CONDUSSIONER
Demolition Permit Sign-Off
(Supplement to permit application)
hereby supply the following releases as part of the
application for a permit to demolish the structure located at
( l7 � "4` , ro .��� and shown on the Assessor's Maps
of as being on Map # S-3 Block # Lot# -ooc,s
The sixth edition of the Massachusetts State Building Code, 780 CMR, states in part: "A
permit to demolish or remove a building or structure shall not be issued until a release is
obtained from the utilities, stating that their respective service connections and appurtenant
equipment, such as meters and regulators, have been removed or sealed and plugged in a safe
manner."
Utilily to be Notified Notice Received b Date Received
Gas
Telephone.
Electric
Public Utilities Munici al
Health Department
! Fire Department
Other-
Other-
Demolition debris hauler: 14,
Location of licensed
demolition debris landfill: , _ "��, jc`
Signature of A licant
Date: c /
Signature of Owner �`` .,� Date:
This sheet must be returned to the Inspections Department along with a completed
application for a permit, a site plan, and any other applicable information and fees.
Demoperm.doi