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farm sa•ocaua.A penal wfio wrutroels mats rhos oachome in mtwo-year period sbmU ant be tssasidetad
a boaseowaa. Suet 9wmeowne Shoff aabndt to the Bundles olfmid.oa a fbM acccpt*k loft
Buildins pB,cid,rhea brJshe be aspoatbk ao aH auk work pcfatmed m,da/�bnUdios perm. •.
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HOMEOWNER'S SIGNATURE44 eC
APPROVAL OF B=ING INSPECTOR 4
Sec other ode for stem code
HOMEOWNER'S EXEMPTION
- The Cock tuts dhae 'any hnimeownen pesfontt ►fig inal;far which a�dbt�paz*Is
s=d o pm+iriom of ibb section(Section 709.1J-uccasing of Coanrvetiou Ssprvivera.
provided do b a homeowner OW"f perom(s)hf Mm to do.owl w cd6 that rad homeowner d�omt
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nipavbw Gov Appcudbs Q.Rules and Regubtiom for 1Jecostog Coestructtw Soperviaota,socam
LM Tbb lmk dsw&Tcrm sa dka icsWu in action pmbkesar.partkoly�when tha I P , m n .bbw
m utilieeeti paroaa b thin ease yam Hard eatomt proceed asabst the tamoemea papa ao k wwild va
Itetmed Sitpatiaar. 710e bome"t OCRing as aipt"bW b srhfsale� s IL .
To cmmt thm da hotacvwncc is Mir aware of kvtm tespomibmilea.sumv !"long"-UPS
of ,in permil applicedon,that the bcmwwrm and*Om brlabe tardastaada the tespoottems aft
supavbm You may cart to amend and adopt web a lmmkadliotios fault is yasr comm=416
CITY OF SALEM, MASSACHUSETTS
PUBLIC PROPERTY DEPARTMENT
IZO WASHINGTON STREET, 3RDFLOOR
SALEM, MA 01970
TEL. (976)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 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: 94 L£vw\ Donn?
/nJ Location of Facility
`Ocei � 2Z Q j
Signaturi of tApplicant Date
FULLY complete the following information:
(PLEASE PRINT CLEARLY)
Name of Permit Applicant
Firm Name,if any
Z A Fle- a)-Fa �1p
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 cM S 150A, and the building permits or licenses are to
indicate the location of the facility.