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Rev. 11/17/23 Dominick Pangallo Mayor City of Salem Building Department 98 Washington Street, 2nd Floor Salem, MA 01970 [PHONE REDACTED] Ext. 42200 Stavroula Orfanos, Building Commissioner Director of Inspectional Services Construction Debris Disposal Affidavit (Note: Required for all demolition and renovation work. Upload this completed and signed document to your Building Permit application only if you did not complete the affidavit online.) In accordance with the Ninth edition of the State Building Code, 780 CMR, Section 111.5 Debris, and the provisions of MGL Chapter 40, Section 54; Building Permit is issued with the condition that the debris resulting from this work shall be disposed of in a properly licensed waste deposit facility as defined by MGL Chapter 111, Section 150A. The debris will be transported by: Name of Hauler: The debris will be disposed of at: Name of Address of Signature of Date