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4 CITY OF SALEM, MASSACHUSETTS
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PUBLIC PROPERTY DEPARTMENT
120 WASHINGTON STREET, 3RO FLOOR
SALEM. MASSACHUSETTS 01970
STANLEY J. USOVICZ, JR. TELEPHONE: 978-745-9595 EXT. 380
MAYOR FAX: 978-740-9846
Salem Building Department
Debris Disposal Form
In accordance with the provisions of MGL c40 S 54, a condition of your
Building Permit is that the debris resulting from this work shall be disposed
of in a properly licensed solid waste disposal facility as defined by MGL
Chapter III, S 150 A.
The debris will be disposed of in:
�e '✓ (Location of Facility) �
gnatur f Applicant
Date
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