Fillable COMMUNITY PRESERVATION COMMITTEE APPLICATION FORMS (City of Somerville)

Fill Online, Printable, Fillable, Blank COMMUNITY PRESERVATION COMMITTEE APPLICATION FORMS (City of Somerville) Form

Use Fill to complete blank online CITY OF SOMERVILLE (MA) pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

COMMUNITY PRESERVATION COMMITTEE APPLICATION FORMS (City of Somerville)

On average this form takes 141 minutes to complete

The COMMUNITY PRESERVATION COMMITTEE APPLICATION FORMS (City of Somerville) form is 23 pages long and contains:

  • 0 signatures
  • 22 check-boxes
  • 555 other fields

Country of origin: US
File type: PDF

U.S.A. forms for City of Somerville

BROWSE CITY OF SOMERVILLE (MA) FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
JOSEPH A. CURTATONE
MAYOR
C
ITY OF
S
OMERVILLE
,
M
ASSACHUSETTS
COMMUNITY PRESERVATION COMMITTEE
FY21 FUNDING CYCLE APPLICATION PACKET
APPLICATION FORMS
JUNE 22, 2020
This packet contains all of the forms that applicants need to submit as part of their FY21
application for Community Preservation Act funds. These forms should accompany the
narrative submission as described in the CPA application instructions packet
. Should you have any
questions during the application process, including if you need language support, please contact Judith
Tumusiime, the Community Preservation Act Manager. She can be reached at
jtumusiime@somervillema.gov or 617.625.6600 x2111
. You can also access additional resources and
videos of application workshops at: www.somervillema.gov/cpa
The following forms are included in this packet:
1. The FY21 pre-application form for community projects proposed for City land and proposals for
feasibility studies (p. 3-4)
2. The FY21 project eligibility form, which must be submitted to and reviewed by the Community
Preservation Committee (CPC) before an applicant can submit a full application. An electronic
version of the project eligibility form is available online
. (p.5-6)
3. Fillable application cover page (p. 7)
4. Fillable submission requirements checklist (p. 8-9)
5. Fillable budget summary (p. 10)
6. Fillable Grant and Trust Fund Disclosure Form (p. 11-12)
7. Fillable Mandatory Campaign Contribution Disclosure and Certification Form (p. 13-17)
8. Ordinance to Safeguard Vulnerable Road Users Acknowledgement (p. 18)
MEMBERS
Jane Carbone, Chair
Laura Beretsky, Vice Chair
Luisa Oliveira
Tatiana Shannon
Amelia Aboff
Eleanor Rances
Heather Heimarck
Cristina Kennedy
Caitlin Hart
STAFF
Judith Tumusiime
JOSEPH A. CURTATONE
MAYOR
Application Process Checklist:
May 25 at 4:30pm: Submit pre-applications (only for
community proposed projects on City land and feasibility
studies)
July 2 at 6:30pm or July 3 at 1:00pm:
Attend virtual application workshops on
GoToMeeting https://global.gotomeeting.com/join/792438397
.
You can also dial in using your phone. United States: +1 (646)
749-3122. Access Code: 792-438-397. New to GoToMeeting?
Get the app now and be ready when your first meeting starts.
July 17 at 4:30pm: Submit eligibility determination form to
jtumusiime@somervillema.gov.
September 3: Attend CPA Manager office hours by
appointment.
September 16 at 12:00 noon: Submit funding applications to
City Hall (93 Highland Ave) by noon
October 28: Present application to CPC (dates tentative)
JOSEPH A. CURTATONE
MAYOR
Submit an electronic copy (fillable PDF available at www.somervillema.gov/CPA
) no later than 12 noon on Wednesday, May 25 to:
Judith Tumusiime at jtumusiime@somervillema.gov. [Download and save file before you begin typing to ensure work is saved.]
The Somerville Community Preservation Committee requires the property owner of public lands be a co-applicant on all projects for
Community Preservation Act (CPA) funding. To propose an idea for a CPA funded project on City of Somerville owned land, submit
this form to the CPA Manager. The Manager will help match you with the appropriate City department who will opt to sign on as a
co-applicant, work with you to develop the idea further for a future funding round, connect you with an existing effort on the
property, or decline to sign on as a co-applicant.
You can also use this form to request a feasibility study be conducted for your proposed project idea- both for projects on City land
and for land that is privately owned. The City does not need to be a co-applicant on feasibility study projects. Feasibility studies are
used to determine the likelihood of a project’s success, strategies for increasing the likelihood of success, and to clarify alignment
with Community Preservation Committee guidelines and goals. If selected, the CPA Manager will make arrangements for the study
to be conducted. Feasibility studies may include public processes to determine the acceptability of the project to the community,
surveys, costing, and technical advice from relevant experts on strategies to ensure the success of the project.
PROJECT NAME: _________________________________________________________________________________
P
ROJECT LOCATION: ______________________________________________________________________________
P
ROPERTY OWNER:_______________________________________________________________________________
P
ROPOSER(S) NAME / ORGANIZATION: _________________________________________________________________
C
ONTACT PERSON: _______________________________________________________________________________
M
AILING ADDRESS: _______________________________________________________________________________
P
HONE: _______________________________
E
MAIL: _______________________________
Please indicate (X) all categories that apply to this project
(at least one). For more detailed information on these
categories, refer to the “Community Preservation Act
Funding Allowable Uses” chart on page 3.
FOR HISTORIC RESOURCES PROJECTS:
Is the resource in a Local Historic District and/or listed on
the State Register of Historic Places?
Yes No
(you can check designation at mhc-macris.net
)
If no, has the Somerville Historic Preservation Commission made a determination that the resource is significant? Yes No
Open
Space
Recreational
Land
Historic
Resources
Community
Housing
(blended
projects only)
Restoration
C
ITY OF
S
OMERVILLE
,
M
ASSACHUSETTS
COMMUNITY PRESERVATION COMMITTEE
FY21 FUNDING CYCLE
PRE-APPLICATION FOR COMMUNITY PROPOSED PROJECTS ON
CITY LAND & FEASIBILITY STUDIES
JOSEPH A. CURTATONE
MAYOR
Please indicate (X) all categories for which you are seeking consideration with this application.
FOR CITY OF SOMERVILLE USE: Date Received _________ Date Reviewed ________ Date Applicant Notified ________
Co-applicant: Relevant department____________________ Co-apply Develop further Join existing Not currently possible
Feasibility study: Fund Don’t fund
City department to sign
on as co-applicant
Feasibility study
funding
P
ROJECT
S
UMMARY
:
P
ROJECT
S
TATUS
(What community need is this trying to address and what level of planning has already been undertaken to
inform the proposed project, including stakeholders engaged to date?):
F
OR
F
EASIBILITY
S
TUDIES ONLY
:
Q
UESTIONS AND
B
ARRIERS TO
I
MPLEMENTATION
(What questions do you think still need to be
answered to help the Community Preservation Committee assess the merits of this project? What barriers to
implementation do you anticipate for the project and how can these be overcome?)
:
C
OMMENTS
:
JOSEPH A. CURTATONE
MAYOR
Submit an electronic copy (fillable PDF available at www.somervillema.gov/CPA
) no later than 4:30pm Friday, July 17, 2020 to:
Judith Tumusiime, jtumusiime@somervillema.gov. [Download and save file before you begin typing to ensure work is saved.]
PROJECT NAME: _________________________________________________________________________________
P
ROJECT LOCATION: ______________________________________________________________________________
A
PPLICANT(S) NAME / ORGANIZATION: _________________________________________________________________
C
ONTACT PERSON: _______________________________________________________________________________
M
AILING ADDRESS: _______________________________________________________________________________
P
HONE: _______________________________
E
MAIL: _______________________________
Interested in collaborating with local artist on your
project? Yes No
Please indicate (X) all categories that apply to this
project (at least one). For more detailed information on
these categories, refer to the “Community Preservation
Act Funding Allowable Uses” chart on the next page.
PROPERTY OWNERSHIP:
Legal Property Owner of Record (if applicable):
__________________________________________
Is the owner the applicant? Yes No
If No, does the applicant have site control or written consent of the property owner to submit an application? City of Somerville
must be co-applicant on all projects on City property.
Yes (Attach documentation)
No (Project will be deemed ineligible for this applicant)
FOR HISTORIC RESOURCES PROJECTS:
Is the resource in a Local Historic District and/or listed on the State Register of Historic Places? Yes No
(you can check designation at mhc-macris.net
)
If no, has the Somerville Historic Preservation Commission made a determination that the resource is significant? Yes No
Open
Space
Recreational
Land
Historic
Resources
Community
Housing
(blended
projects only)
Restoration
P
ROJECT
S
UMMARY
:
C
ITY OF
S
OMERVILLE
,
M
ASSACHUSETTS
COMMUNITY PRESERVATION COMMITTEE
FY21 FUNDING CYCLE
E
LIGIBILITY DETERMINATION FORM
JOSEPH A. CURTATONE
MAYOR
FOR CPC USE: Date Received _________ Date Reviewed ________ Date Applicant Notified ________
Eligible Potentially Eligible Not Eligible More Information Needed
C
OMMENTS
:
P
ROJECT
S
TATUS
(What community need is this trying to address and what level of planning has already been undertaken to
inform the proposed project?):
JOSEPH A. CURTATONE
MAYOR
1. P
ROJECT INFORMATION
P
ROJECT NAME: _________________________________________________________________________________
P
ROJECT LOCATION: ______________________________________________________________________________
L
EGAL PROPERTY OWNER OF RECORD: __________________________________________________________________
O
NE SENTENCE DESCRIPTION OF PROJECT: ________________________________________________________________
_____________________________________________________________________________________________
Please indicate (X) all categories that apply to this project (minimum of one) in the chart.
ESTIMATED START DATE: ____________________
E
STIMATED COMPLETION DATE: _______________
CPA
FUNDING REQUEST: ____________________
T
OTAL BUDGET FOR PROJECT: _________________
2. A
PPLICANT INFORMATION
A
PPLICATION NAME / ORGANIZATION: _________________________________________________________________
C
O-APPLICATION NAME / ORGANIZATION: _______________________________________________________________
C
ONTACT PERSON: _______________________________________________________________________________
M
AILING ADDRESS: _______________________________________________________________________________
P
HONE: ________________________________________ EMAIL: ________________________________________
3. S
IGNATURES
I (we) certify that all information provided in this entire submission is true and correct to the best of my (our) knowledge and
that no information which might reasonably affect funding has been excluded. I (we) authorize the Community Preservation
Committee and/or the City of Somerville to obtain verification from any source provided.
Name (printed) ____________________________ Signature _______________________________ Date _______________
Name (printed) ____________________________ Signature _______________________________ Date _______________
Open
Space
Recreational
Land
Historic
Resources
Community
Housing
(blended
projects only)
Acquisition
Creation
Preservation
Support
Rehabilitation/
Restoration
C
ITY OF
S
OMERVILLE
,
M
ASSACHUSETTS
COMMUNITY PRESERVATION COMMITTEE
FY21 FUNDING CYCLE
A
PPLICATION COVER PAGE
JOSEPH A. CURTATONE
MAYOR
Please check () each item included in your submission, which should include the applicable items in the order
listed below.
G
ENERAL:
Application Cover Page (form provided)
Submission Requirements Checklist (this form)
Narratives (prompts provided in instruction packet)
Project timeline: a project schedule showing all major milestones (i.e., study, design, environmental,
permitting, construction, etc.), including receipt of other funding sources
Grant and Trust Funds Disclosure Form (form provided)
Campaign Contribution Mandatory Disclosure and Certification Form (form provided- only needed if
requesting $50,000 or more in CPA funds)
Ordinance to Safeguard Vulnerable Road Users Acknowledgement (form provided)
F
INANCIAL:
Budget Summary (form provided- construction projects must include cost for permanent CPA dedication
sign)
Itemized budget of all project costs, including the proposed source for each cost
Three written quotes for project costs. If quotes cannot be secured, detailed cost estimates may be used
if a thorough explanation of the estimates is included.
Proof of secured funding (e.g., commitment letters or bank statements), if applicable. If providing bank
statements, please redact identifying information such as account numbers.
V
ISUAL:
Map of the property location showing all features pertinent to the project, including current or future
rapid transit stations
Photos of the project site (not more than 4 views per site); include digital copies
O
WNERSHIP/OPERATION (NON-CITY):
Documentation of site control or written consent of the property owner to undertake the project, if the
owner is not the applicant
City has signed on as a co-applicant for community projects proposed on City land.
Certificates of Good Standing from the City and the State
, if applicable
501(c)(3) certification, if operating as a non-profit
Purchase and sale agreement or copy of current recorded deed, if applicable
C
OMMUNITY SUPPORT (RECOMMENDED):
Letters of support from residents, community groups, other City boards, commissions, or departments, or
from City, state, or federal officials
C
ITY OF
S
OMERVILLE
,
M
ASSACHUSETTS
COMMUNITY PRESERVATION COMMITTEE
FY21 FUNDING CYCLE
S
UBMISSION REQUIREMENTS CHECKLIST
HISTORIC RESOURCES PROJECTS:
Documentation that the project is listed on the State Register of Historic Places or a written
determination from the Somerville Historic Preservation Commission that the resource is significant in the
history, archeology, architecture, or culture of Somerville.
Photos documenting the condition of the property
Report or condition assessment by a qualified professional describing the current condition of the
property, if available.
P
LANS AND REPORTS (IF AVAILABLE; SUBMIT DIGITAL COPIES ONLY)
Renderings, site plans, engineering plans, design and bidding plans, specifications, and any MAAB variance
requests
Applicable reports (e.g., 21E, historic structure report, appraisals, survey plans, feasibility studies).
JOSEPH A. CURTATONE
MAYOR
P
ROJECT NAME: _________________________________________________________________________________
A
PPLICANT: ____________________________________________________________________________________
S
UMMARY OF
P
ROJECT
C
OSTS
Please include a complete itemized budget of all project expenses, including the proposed funding source for each expense, in
your submission. Budget needs to include cost of permanent CPA dedication sign if requesting construction funds.
PROPOSED SOURCE
EXPENSES
STUDY
SOFT COSTS*
ACQUISITION
CONSTRUCTION**
TOTAL
1 Somerville CPA
2
3
4
5
6
TOTAL PROJECT COSTS
*Soft costs include design, professional services, permitting fees, closing costs, legal, etc.
** Construction includes new construction, preservation, rehabilitation, restoration work, and/or accessibility related
expenses
E
XPLANATION OF
F
UNDING
S
OURCES
Please explain the status of each funding source (i.e., submitting application on X date, applied on X date, received award
notification on X date, funds on hand, etc.). For sources where funding has been awarded or funds are on hand, please include
documentation from the funding source (e.g., commitment letter, bank statement) in application packet
SOURCE
S
ECURED
?
(YES/NO)
STATUS OF FUNDING SOURCE
1
2
3
4
5
C
ITY OF
S
OMERVILLE
,
M
ASSACHUSETTS
COMMUNITY PRESERVATION COMMITTEE
FY21 FUNDING CYCLE
B
UDGET SUMMARY
GRANT AND TRUST FUNDS DISCLOSURE FORM
PURSUANT TO CITY OF SOMERVILLE CODE OR ORDINANCES SEC. 15
(copies of the Ordinance are available upon request)
Instructions: All applicants for grant and/or trust funds administered by the City must complete this form as
part of its application submission to the City of Somerville. Complete all sections of this form.
Section 1
Legal Name of Applicant:
Indicate whether the applicant had any grant, contract, or agreement with a federal, state or local agency
terminated within the last three (3) years.
Check One
:
Yes (If yes, please identify the grant, contract, or agreement including parties, term,
and cause of termination on an additional page.)
No
Section 2
Applicants are required to disclose any circumstances constituting a conflict of interest or potential
conflict of interest arising from or relating to the proposed grant or trust disbursement, whether real or
apparent.
Conflict of Interest Prohibited. No employee, officer or agent of the grantee shall participate in any
particular matter, including but not limited to, the selection, or in the award or administration of a
contract, grant or subgrant, or employment agreement administered by way of funds received by the
City of Somerville if a conflict of interest, real or apparent, would arise. Such a conflict would arise
when:
1) an employee, officer or agent, or
2) any member of his or her immediate family, or
3) a business organization in which he or she is serving as officer, director, trustee, partner, or
employee; or
4) any person or organization with whom he or she is negotiating or has any arrangement concerning
prospective employment,
has a financial or other interest in the person or entity selected for an award, or a contract, grant,
subgrant, or employment agreement of the grantee or the funds for which originate from or are awarded
through the city.
Check One: No Conflict Of Interest
Potential or Actual Conflict of Interest (If checked, disclose in detail all
relevant facts, including names of individuals or organizations, relevant contract,
grant, subgrant or employment agreement, and source of funding on an additional
page.)
1
Section 3
Attach a copy of applicant’s policy addressing conflicts of interest that may arise involving management,
employees and the members of its board of directors or other governing body. See the City of Somerville
Code of Ordinances Section 15-42(c) for complete requirements. Should the policy be revised during the grant
term, a copy of the revised policy must be submitted to the City within thirty (30) days of being revised.
Section 4
Identify all officers, employees, contractors, subgrantees or other persons providing any type of service in
relation to the proposed grant activity, in the following format. Use additional page(s) as necessary.
Name (Individual or
Entity)
Association
Service Provided
Value of
Service ($)
Amount of City
Funds
Supporting
Service ($)
Mark “X” if
individual or
entity has had
any grant,
contract, or
agreement with
a federal, state
or local agency
terminated
within the last 3
years.*
*If yes, please identify the grant, contract, or agreement including parties, term, and cause of termination on an additional page.
Section 5
This form is hereby completed on behalf of the applicant named above. Through the undersigned
individual, the applicant hereby certifies that the completed form is true and accurate. The applicant
acknowledges that it has read, understands, and agrees to comply with, the requirements of City of
Somerville Code of Ordinances Section 15.
During the term of any grant, grantees have a continuing obligation to submit an updated Disclosure
Form to the City of Somerville immediately as to any circumstances which constitute a potential or actual
conflict of interest.
Signature:
Print Name of Authorized Individual:
Title:
Date:
2
1
CITY OF SOMERVILLE CAMPAIGN CONTRIBUTION ORDINANCE SEC. 15-72
*
MANDATORY DISCLOSURE AND CERTIFICATION FORM
INSTRUCTIONS: APPLICANTS, PLEASE COMPLETE THE ENTIRE FORM AND FILE WITH THE
SAME CITY OFFICE OR AGENCY WITH WHOM YOU FILED OR WILL FILE BELOW APPLICATION.
PART I. APPLICATION FOR ITEM
Describe the item you have, or will apply for, relating to this disclosure:
ITEM:
TYPE (X):
__ Contract __ Zoning Relief __Real Estate __Financial Assistance
CITY DEPT. OR
AGENCY:
PART II. APPLICANT INFORMATION
Provide the following information for the Applicant:
NAME:
ADDRESS:
TELEPHONE NO.:
E-MAIL:
On Schedule A, you must also provide the same information for the Applicant’s principals, chief executive
officer, president, chief financial officer, treasurer, chief operating officer, chief procurement officer, directors,
or persons performing similar functions, or shareholders in excess of ten percent and managing agent to the
extent applicable. Please complete Schedule A. If not applicable, please check N/A on Schedule A.
PART III. CAMPAIGN CONTRIBUTION DISCLOSURE
On Schedule B, Applicants must disclose all contributions made by the applicant during the 12 months prior to
the application (identified in Part I), to any person who was a candidate for elective office of the City of
Somerville (mayor, board of aldermen, and school committee). The attribution rules in Section 15-73 of the
Somerville Code of Ordinances shall apply to the contributions that must be disclosed. On Schedule B,
applicants must also disclose such contributions made by persons attributed to the applicant under the
ordinance. If the applicant is an individual, any such contributions made by the individual, any spouse of the
individual, and any children of the individual must be disclosed. If the applicant is not an individual but a
corporation, partnership or limited liability corporation, then any contributions made by any of its chief
executive officer, president, chief financial officer, treasurer, chief operating officer, chief procurement officer,
directors, members, managers, principals, or persons performing similar functions, or shareholders in excess of
ten percent, and their spouses and children, must be disclosed. Please complete Schedule B. If disclosure is
not required, please check N/A on Schedule B. Note: Contributions made before January 1, 2017 are not
required to be disclosed.
*
Please see the Pay to Play and Campaign Contribution Ordinance for definitions and all requirements.
v1.12.17
2
PART IV. SUBCONTRACTOR INFORMATION
Have you applied for a Contract and intend to use a subcontractor on this Contract?
Yes
No
If “Yes”, complete Schedule C. If “No”, proceed to Part V.
PART V. SIGNATURE, CERTIFICATION, AND ATTESTATION:
I, the undersigned applicant, hereby further certify as follows: If awarded the item that is applied for (as
identified above) under subsections (a), (b), (c), or (d) in Section 15-72 of the Somerville Code of Ordinances,
the Applicant, and anyone attributed to the Applicant, and if the application is for a contract any subcontractor
used on the contract, will not make any contribution in any calendar year in an amount in excess of $500.00 to
any individual incumbent or to any individual candidate for elective office of the City of Somerville for the next
four (4) calendar years following the award of the item, or for the duration of the term of the contract,
whichever is longer.
Signed under the pains and penalties of perjury:
Signature of Affiant:________________________________Title:_______________________________
Printed Name of Affiant:___________________________ Date:______________________
Subscribed and sworn before me this ___ day of
___________, 2___.
My Commission expires:
(Witnessed or attested by)
(Seal)
THIS FORM SHALL BE OPEN TO PUBLIC INSPECTION
3
SCHEDULE A – APPLICANT INFORMATION
INSTRUCTIONS: FOR EACH OF APPLICANT’S PRINCIPALS, CHIEF EXECUTIVE OFFICER,
PRESIDENT, CHIEF FINANCIAL OFFICER, TREASURER, CHIEF OPERATING OFFICER, CHIEF
PROCUREMENT OFFICER, DIRECTORS, OR PERSONS PERFORMING SIMILAR FUNCTIONS, OR
SHAREHOLDERS IN EXCESS OF TEN PERCENT AND MANAGING AGENT TO THE EXTENT
APPLICABLE, COMPLETE THE FOLLOWING. ATTACH ADDITIONAL PAGES IF REQUIRED.
IF NOT APPLICABLE, CHECK HERE: ___.
NAME POSITION E-MAIL ADDRESS PHONE NO. ADDRESS
4
SCHEDULE B– CONTRIBUTION DISCLOSURE INFORMATION
INSTRUCTIONS: FOR EACH CONTRIBUTION, YOU MUST DISCLOSE THE FOLLOWING
INFORMATION. ATTACH ADDITIONAL PAGES IF REQUIRED.
Note: Contributions made before January 1, 2017 are not required to be disclosed.
IF NOT APPLICABLE, CHECK HERE: ___.
NAME OF
CONTRIBUTOR
RELATIONSHIP
TO APPLICANT
NAME OF
RECIPIENT
DATE OF
CONTRIBUTION
(MM/DD/YYYY)
AMOUNT OF
CONTRIBUTION
($.$$)
5
SCHEDULE C – SUBCONTRACTOR INFORMATION
INSTRUCTIONS: LIST THE NAME, BUSINESS ADDRESS, AND PHONE NUMBER OF EACH
SUBCONTRACTOR AND THE AMOUNT OR PERCENTAGE TO BE PAID TO EACH
SUBCONTRACTOR. ATTACH ADDITIONAL PAGES IF REQUIRED.
NAME
AMOUNT OR
% PAID
PHONE NO.
BUSINESS ADDRESS
SOMERVILLE ORDNINANCE TO SAFEGUARD VULNERABLE ROAD USERS
CITY OF SOMERVILLE CODE OF ORDINANCES ARTICLE VIII, SEC. 12-117 et seq.
___________________________________________________________________________
Prospective contractors must familiarize themselves with the City of Somerville’s Ordinance to Protect Vulnerable
Road Users. The full text of this local law can be found here
.
1. Request for Inspection: Inspections are conducted on Thursdays from 4pm-7pm at the Somerville Department of
Public Works, located at 1 Franey Road. Each inspection takes approximately 20 minutes.
a. Any vendor covered by this Ordinance shall complete an inspection request form and email it to
fleetinspections@somervillema.gov
.
b. Please submit request form no later than 3pm on the Tuesday before the requested inspection date.
2. Fee: The fee for the initial inspection is $100. The fee for a renewal inspection (every two years) is $50.
a. Payment of the fee is due upon scheduling of the inspection. The fee can be paid via check or credit card.
Checks should be made out to the City of Somerville and include the vendor’s phone number.
3. Approval: Vehicles inspected and approved by the Fleet Division will have an inspection approval sticker affixed
to the windshield of the vehicle. A copy of the inspection report and certificate of inspection shall be issued to the
vendor.
a. Inspection stickers are not transferable.
b. Any major overhaul of safe guard equipment shall be required to be re-inspected.
4. Rejection: If a vehicle is rejected for failing to comply with any of the technical specifications outlined in the
ordinance, it shall be corrected and henceforth re-inspected within 30 days at no additional fee.
a. If a second inspection results in a rejection, a fee of $50 will be required for any subsequent inspections.
b. Any vendor who fails to comply within 60 days of their first inspection may be subject to having their contract
cancelled.
5. Questions: Please direct questions about vehicle inspections to Fleet Superintendent Ron Bonney at
rbonney@somervillema.gov
or at (617) 625-6600, ext. 5524.
Acknowledgement
In accordance with Sec. 12-119 “Requirements” in the Ordinance, bidders must sign the following:
Unless certified that the Ordinance is not applicable to this contract or otherwise waived by the City, I acknowledge that
my company has installed (or will install prior to commencing work for the contract) side guards, cross-over mirrors or
equivalent blind spot countermeasures, convex mirrors or equivalent blind spot countermeasures, side-visible turn
signals, and appropriate warning signage, in accordance with SCO Chapter 12, Article VII on all large vehicles it uses
or will use within the City of Somerville in connection with any contract.
Authorized Signatory’s Name Date
Company Name
I certify that the Ordinance does not apply to this contract for the following:
Vehicles do not meet or exceed Class 3 GVWR Vehicles do not exceed 15 MPH No vehicles on project
Other:
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

COMMUNITY PRESERVATION COMMITTEE APPLICATION FORMS (City of Somerville)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 5 August 2020

Message

View Audit Log
Print With Audit Log
Duplicate Document