9 LAWRENCE ST - BUILDING INSPECTION (4) � i a
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TD A`.lPJM W AlZM ORAMft
CITY OF SALEM
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TO THE INSPECTOR OF BLALOING& '
The undwsorrd tweby applin for a pomk to build a000r*fp.to tlfe.foNoarlrfp
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MAIL PERW TO,
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PUBLIC PROPUM DEPARTMOff
120 WASHINGTON IRMUQ,3ND FLOOR
aAli11.MA 01 Y70
TaL (978)745-MOO Cu.a!o
FAX (Y74) 740•98"
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DLSPOSAL OF DEBRM AFFIDAVIT
In scowdence widl d w provisions of MM c 40,SK I acknowledge dw as a condition
of Bm'l ft Puma/ .all debm mulling ffom the construction adWo
govarmd by dl»s Building Permit did be diapered of in a ptopulyr Hcuiaed soH&w"M
disposal SeBiry.as defined by MGL c A S1SM
The ddbrie wM be disposed of at /u S le/L—
Locaoonoffrum r
Swat=ofpacnitwmmd Dads
FLILLY OULUE PPRRWr CLEARRL )ing mfosmatroo..
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Name OfPelmrt APPLca&
Fnm Name,if nay
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Addl'ess.City dt State - - -- -- ---
The above stMft requim dial debris fiom the denolitioq renovation.Irchab or other
skaadon of bml t'og or structum be disposed in a propaly-licensed solid-waste disposal
facility as defined by M(3L cML S150A.and the building permilm a liceasses afe to
indicate the locadon of dw li cflky
Crnr OF SALEM
BUUMING DEPARTNIEW
HO MOWNE1t LICENSE EXMMON
Plata Prig
DATE [" U-6p
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TELEPxaN9 q J
PRESPNf Itd 2WP ADDRESS G Lit/I//t h t• t O.
Tbc nareat.exa Cgi of-homwwwc was cmcnda w bcladc a" r oceop"dwcl6p elTwo
Units a lest sad to a11ow such borseowaas b sagaye a►indhido�l'hit Itbs xLo doa aol pwsas t .
liocme..prwidrd dm the ewocr ael as swtcniast:
DErftQT101'I OF)IOMEOWH= b raids.on addefi Dias is.ar Y
Pcrtoo(s)wbo ons w a parcel of lad on whkb blshe Ics(da a breads b ta3 tse aldlk
intaaded to bc,s one to twv fondly dwcllinf,shaded of dctsd"saucnaa sbal slot be tansldaad
farm svucoaes.A ptr m who mntvuets arse than cac bomt in a two-7 oa s coop sr=ptaDis b!M
Bwldinc Officn4t7ffiC's45 t1 bt nspon 'bk m aA rock work pafa'med ands the bow pawl.
The undcaipKd-boaxowue an m cs raponsibmv for c=plsw=wmthc State Bmu ft Code and
otha appGobk Sea by-bws,rula aced resubdas
Tbc WA=ipd-homcowme=dfm ihm hdshc the sty of StlemBnTidto�.Deparanas.
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HOMEOWNER'S SIGNATURE
APPROVAL OF B=ING INSPHC'I03t
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