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APPROVAL OF BLWING IIiSPECi OR
See area side for sass code
HOMEOWNER'S EXEMPTION
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CITY OF SALEM9 MASSACHUSETTS
PUBLIC PROPERTY DEPARTMENT
120 WASHINGTON STREET, 3RO FLOOR
SALEM.MA 01970
TEL (979)745-9595 EXT. 360
40 FAX (976) 740-9646
STANLEY J. USOVICZ. JR.
MAYOR
DISPOSAL OF DEBRIS AFFIDAVIT
In accordance with the provisions of MGL c 40,S34,I acknowledge that as a condition
of Building Permit d .all debris resin ing from the construction activity
sovaned by this BuildingPennit shall be disposed of in a properly licensed solid-waste .
disposal facility.ss defined by MGL c IA.S1SOA.
The debris will be disposed of at: 9� /t° 17� 2L. v
Location of Facility
Signature of Permit Applicant Date
FULLY complete the following information:
(PLEASE PRINT CLEARLY)
L& f� U� v
Name of Permit Applicant
Firm Name,if any
Address,City dr 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 ca S 1 SOA, and the building permits or licenses me to
indicate the location of the facility.
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