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PUBLIC PROPERTY DEPARTMENT
120 W^8HJNaTDN arrRaaT, aRD FLoom
SALLM,MA O t S70
TEL. (E78)745-"95 WIT.a!o
FAX (979) 740-984e
STANLEY J. USOVIM JR.
MAYOR
DISPOSAL OF DEM AFFIDAVIT
In aocord=m with the provisions of M(IL c 40.M I aclmowledse that as a coedit m
of Bw7d'mg Permit S .A debris resukbg from the c=suucdm,arvy
govamed by this BuDdins Permit sW be disposed of in a properly licensed aolid-waste
disposal balky.as defined by MCL cc 111;,S150A.
The debris wig be disposed of at;
Lacatioa'ofFacility
"Sliditme ofPermitAPphcW Doe
FULLY ComPlete the fDllowi)g inf msdm
(PLBASB PRW CLEARLY)
Name of Pcm*A"Heaot
Fnm Name.ifwW
� S- G#/ais ////
Add<as.City&State
The above statute requires that debris from the demohti
on.rraovatron,rehab or other
alteration of bufldmg or starches be
disposed m a properly-liceaaed solid-wWe
Ad*as defined by MGL dM S150A,and the building permits or licences are to
indrate the location of the facility.
CITY OF SALPM
BUILDING DEPARTIAM
HOMBOWN]R UCENSE DMOnON
Pkm Prig
DATE G '`�-O
)OB LOCATION S G/���C2eI5 fir/�l c�0
1401acwr>ER
ADDRESS
•HOMEOWI�I �'/ �� PSIS''
TELEPHONE
p��PiI'MA]11NG ADDRESS S�N � •
The C11TiCd C,C1I1PU011 Of-lion.COWDCfC W5a C=Uded to b CIV o owner-occupkd dwelsaja CCTWO
indrstdhtgl.foe bta A'�doea DOl p06Ka/S
UDlts of kss and to allow such hotncowrAU 10 engage an
L'«use,provided tbn the owat r ad as overview.
DEFaanaN OF HOWIEMMl on whk efe 1k a b
PCmaD(s)who owns a Fame,of land an which hclshe fesida of suu s to faille, h th
10 nseb rose mkr
intanded to be,a one to two family dwelling amadhed of detaelrcd odshalf tnasidefed
farm suu=v .A prnm who constructs m m them one home in a two y Pe^
S -homed homeowner sh-Z r&u&to the Building teal,on a form am�t"fo As
a bomcowDu. bk to all such work POWTmed WA=the building pertttirL
Building OMeial,that bclshc be responsh
Tac undersigned"bomeowtaa"asmm im Tesponnbility for wmpliwl whtb the State BDDdlmg Cote and
other applicable goes by-law;TWO"d tegulalic=
cer Mcs that he/she undcatands the City of Sakm BDildmg Depaftmd
The undcsignecumprowt will eoWly with sadP Wd
. minimuDD iruspction procedures and regtnremhems and that hlshe
fcquirc�
HOMOVITIER*S SIGNATURE
APPROVAL OF B=ING INSPECTOR
Sec other sde for State Cade
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14
HOMEOWNER'S EXEMMON
The cods shies that: 'arq homeownr performing work for.vWcb a building permit is regtmed sbal be
exempt from the pm wens of this section (Section 30P.1.1-11cenaing or Construction Supervisors);
Provided that is a bonneowner tngaga a person(s)far hie to do.such worst,timt sineb howwwau ahap ad
as
Mw7 borneowners who use this exemption are unaware that they are Lsswnbg the tapom Mdas dl
supervisvt (sa Append$Qr Rules and Reguianions for Liacmaimg Construction Supervisors,See"
.2.iiS} This lack of awareness ofttu resdu in scrioms yrobkms parnNlsr)y when she b mu6owr=bhu
unlicensed pc=M In INS Case your Board Cannot proceed againg iht unlicensed person ar it wvuiti WI&
licensed Snpenisor. Tbt bomta„ver acting as supervisor it oWmase)(y rnroosiblb,
To tusurt that the homeowner is My aware of hillier mpown'bMiles,marry eermnnmdda ftgd .as past
of the permit application.that the bomeo vncr cereify that bdshc understands the ruponsibnW=der
supervimt. You may cart to a nand and adopt such a formltxrtification for ism in your