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•Wf Massachusetts
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212 a n Street • Bu clpal Building
Morthampton, tl 01060
CONSTRUCTTON DEBRIS AFFIDAVIT
(FOR ALL DEMOLITION AND RENOVATION PROJECTS)
In accordance of the provisions of MGL c 40, 554, a condition of Building Permit
Number is that all debris resulting from this work shall be disposed of in a
properly licensed waste disposal facility, as defined by MGL c ill, S 1SOA.
The debris will be disposed of in: 1
Location of Facility: D u am n5 4v q I n u f S 0 7
001 51 fla n J`7.4
The debris will be transported by:
Name of Hauler: )�Vr" Ct 7haw1
Signature of Applicant: __(> t"_' Date:
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