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APPLICATION FOR
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LOCATION
PEFWNT GRANTED
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INIFECTOR
CR'Y OF SALEM
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HobCOWNEIL'S SIGNATURE
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APPROVAL OF BUIlDING]NSPECTOiI
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CITY OF SALEM
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HOMEOWM LICENSE EMOMON
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)iOWOWM'S SIGNATURE
APPROVAL OF BUIIDING INSPECT0ii
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+ CITY OF SALEM, MASSACHUSETTS
PUBLIC PROPERTY DEPARTMENT
120 WASHINGTON STREET, 3RD FLOOR
SALEM, MA 01970
TEL. (978)745-9595 ExT. 380
40 FAx (978) 740-9846
STANLEY J. USOVICZ, JR.
MAYOR
DISPOSAL OF DEBRIS AFFIDAVIT
In accordance with the provisions of MGL c 40, S34,I aclmowledge 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, S 150A.
The debris will be disposed of at:
Location of Facility
S�gnafure of Permit Applicant Date
FULLY complete the following information:
(PLEASE PRINT CLEARLY)
M A kV
Name of Permit Applicant
Firm Name,if any
( � L�NcoC/j
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 properly-licensed solid-waste disposal
facility as defined by MGL cIII, S 150A, and the building permits or licenses are to
indicate the location of the facility.