Scan 2City of Northacpstoa
'
OF
M 01040
CONSTRUCTION DEBRIS AFFIDAVIT
(POR ALL DEMOLTRON AND RENOVATION mctJ fs)
In accordance of the provisions of MGL c a0, SM, a condition of Building permit
Number Is that all debris resulting from this work shall be disposed of in
Properly licensed waste disposal facility, as defined by MGL c 111, S 150A.
The debris will be disposed of in:
Location of Facility: z¢ fI 1�beh(/1/�e "�• ecl /'"1
The debris will be transported by:
Name of Hauler: l (Vitt �ry i:(
Slgnatureof Applicarn;