17 LEACH ST - BUILDING INSPECTION 1
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CITY OF SALEM
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TO THE INSPECTOR OF BLMLORMO '
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PUBUC PROPERTY DEPARTMENT
120 WASHINGTON STRaaT, aRDFLOOR
aALIEW MA 01 a70
TaL(978)7411-MOO KILT.a!O
FAX (678) 740404"
STANLEYJ..YUSOV=& JIL
MA
DISPOSAL OF DEBRIS AFFIDAVIT
In wcmd=m with d a povW=of UM c 4%SK I wJmowlo*fat as a cooditim
OfBm'Idiag Permit/ -d debris resulting fi m 69 cmwocbm
governed by this Bm'ldiog Punk dM be disposed of in a properly licound pyd waaee
disposal .as defined by UM a nL SI
Thu debds wM be disposed of at: �JiyBSt�_.
Loca m of Feces
Sigma ofPeradt 'eab ly all
Dab
FULLY compkb the folbwiog iofomtatim
0UWE PRW CLBARL
Name ofPe>oaitApifficad
FG Name,if my
Addrook city a State
The above atawrte mgmm that debris fi=the dmlolitim rmovadon,rd ab or OdW
slteradm of bmlft or wucmm ba d qwm d in a popaly-ficaapd som"asb disposal
fid ty sa defined by MGM,cID.Sl-V&and the budding permib or licmra are to
iadncata the beadco of the faLa ky.
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do hsreby'a.'er* gnaw tps paw and pool" of Mrlw!• dM ,
previd m wrorkeraa cow pou"dw coveralls for Mw siglesees worm"w
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1 am:atoll preprkrw and haw no ons waarkblg fir me in JMF oNeb•
() I am a ataels proprkw, general comraaaaer or homevwnw (fie aame) and how lid do
Meted beletr who-la" tW topowirK worker' mi I Ooddm
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Coasattaoasr Insuratics Contpwry/ o N
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Com rsaff Inurance Cocnpacq/
() 1 am a homsowrw performing all the work aeryaeff.
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raaq,wrwwrw a 0 a e.l gnaw in Jn w=at(a STOP WORK ORDER ow a h"of %100
Signed this . a `� day of
:;ccrsceiFcrmncse ou11a3in�Dtpsrzrkent
Jcensing Eoare
Seiectm w Office
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