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APPLICATION FOR
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APPROVrED
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ECTOii OF B 0908
CITY OF SALEM9 MASSACHUSETTS
PUBLIC PROPERTY DEPARTMENT
120 WASHINGTON STREET, 3RD FLOOR
SALEM, MA O1970
TEL. (978)745-9595 EXT. 380
40) FAX (978) 740-9846
STANLEY J. USOVICZ, JR.
MAYOR
DISPOSAL OF DEBRIS AFFIDAVIT
In accordance with the provisions of MGL c 40, S34,I aelmowledge 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,SS 150A.
The debris will be disposed of at: 6r' Y 4-t>�,�- �c
Location of Facility
le e( JI—)
Signature of Permit Applicant Date
FULLY complete the following information:
(PLEASE PRINT CLEARLY)
Na
me of Peri t Applicant
Firm Name, if any
Address,City& Stati
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.