316 JEFFERSON AVE - BUILDING INSPECTION a •
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PUIM P"01f r UMMY A OOYPLE lLY TO AVOM M An w MIOON�Ir
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The n1h hsrft qVW. br a PwW to bul d 0000aft loft IdMwlry
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r -Pusuc PROPERTY DErARTMENT
120 WA/MIM M M W MaaT. aRD FLOOR '
SALSK MA 01 D70
TEL (276)745-9595 EXT.360
FAX (976) 740-9646
STANLEY J. U60VWZ. JR.
MAYOR
DISPOM OF DM=AFFIDAVIT
In accoidaoce with the pmvuions of MOL c 40.041 wbwwledge that as a condition
of Bml ft Pam*0_ .all debris sesultMg ft m the cozWmcbon aftyay
governed by WE Buil ft Pe®it shaft be disposed of iR a FW*Hceased soH&wasts
disposal facility,as defined by M($.a B;S13M.
The debris wiD be disposed cf st / /S l4
LocadonofFaa'My 0
/ m o
Sigosum of Pit AppHcaat
FULLY complete the fonowmg mf t
(PLEASE PRDC CLEARLY)
Name of Palma AppHcmt
l &eo
Finn Name,ifany
Address,City a State
The above statute mquucs that debris ftm the demolitio%movmdczn mhab or otterr
alteration of bail ftg or st ucmm be disposed in a properly-Hemaed solid-warts disposal
fid tf m&*W by MGL cnL S130A,and the bWldigg permits or Hcentes are to
itldieate the location of the&Wily.