IMG_1287City of Northampton
Massachusetts
DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street • Municipal Building 's
Northampton, MA 01060
Debris Disposal Affidavit
In accordance of the provisions of MGL c 40 S541 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 properly licensed solid waste disposal facility, as defined by MGL c 111, S 150A.
The debris from construction work being
r
Please print house number and street name)
Is to be disposed of at:
at:
Otlhj.Ste W01 alG'`I
(Please pririt name and location of facility)
Or will be disposed of in a dumpster onsite rented or leased from:
pany Name and Address)
m
or Owner Date
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.