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Permit to: BUILDING POW APPLICATION FOR:
(Chb WhMwwr apply) Roof. Remo(, InsW Skft Construct Osok Shed, PooL
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PLEASE PILL.Wr LEfI WY A COYPLEMY TO AVOID DELAW IN PAOCZ@"o
TO THE INSPECTOR OF BUILDINGS:The '.
ndKSIPod hereby applies for a pernk to WW aoow&%to tlw t lwaft
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CITY OF SALEM9 MASSACHUSETTS
PUBLIC PROPERTY DEPARTMENT
� 40 120 WASHINGTON STREET, 3RO FLOOR
SALEM,MA 01970
TEL. (978)745-9593 EXT. 380
FAX (976) 740.9646
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,S150A.
The debris be disposed of'at:
Location of Facility
L - ps
Si of Permit App 'cant D
FULL complete the followL information:
(PLEASE PRINT CLEARLY)
Name of Permit Applicant
Firm Name,if any
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 property-licensed solid-waste disposal
facility as defined by MGL ca S I50A, and the building permits or licenses are to
indicate the location of the facility.
CITY OF SAL'FM
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