DisposalCity of Northampton
•t'
Massachusetts
l DEPARTMENT OF BUILDING INSPECTIONS
212 Main street • Municipal Building Citi,b
t Northampton, MA 01050
Debris Disposal Affidavit
In accordance of the provisions of MGL c 40, S54, I acknowledge that as a condition of the building
permit all debris resulting from the construction activity governed by this Building Permit shall be disposed
of in a property licensed solid waste disposal facility, as defined by MGL c 111, S 150A.
The debris from construction work being performed at:
I Ku� 5 -t- PyV-Q,
(Please print house number and street name)
Is to be disposed of at:
(Please print name and location of facility)
Or will be disposed of in a dumpster onsite rented or leased from:
R10111- efy
(Company !Name and Address) � ` L
G r -e _� f i P.l M d 1.To `I
Sin re of Pe7 it Applicant or Owner Date
r
If, for any reason, the debris will not be disposed of as indicated, the Applicant or Owner shall notify the
Building Department as to the location where the debris will be disposed.