City of Beverly

Community Preservation Committee

Planning Department

191 Cabot Street, City Hall

Beverly, MA 01915

(978) 921-6000 ext. 2343 (978) 921-6187 (Fax)

Staff Contact: Amy Maxner

CPC Website: http://www.beverlyma.gov/boards-commissions/community- preservation-committee/

2015 PRE-APPLICAION PROJECT ELIGIBILITY DETERMINATION FORM

*This form must be submitted to the CPC by Friday February 27, 2015 at Noon

*For historic preservation projects: A Determination of Historical Significance made by the Historic District Commission (HDC) must be submitted to the CPC no later than March 11, 2015. The HDC’s application deadlines for Historical Significance Determinations are: January 14, 2015 to be considered at the January 28, 2015 meeting & February 11, 2015 to be considered at the February 25, 2015 meeting.

The purpose of this form is to ensure all projects applying for Community Preservation Act funding meet the basic requirements of the CPA. This form must be reviewed and approved by the Community Preservation Committee before the applicant can submit a full application.

Project Title: ______Project Location/Address: ______
Date: ______
Name of Applicant: ______
Organization: ______
Contact Person: ______
Mailing Address: ______
Telephone #: ______
Fax#: ______

Email Address: ______

/ If Different From the Applicant:
Name of Owner: ______
Mailing Address: ______
Telephone #: ______
Fax#: ______
Email Address: ______
CPA Category (Check All That Apply):
q  Open Space
q  Historic Preservation
q  Community Housing
q  Recreation / Project Purpose: (Please Refer to DOR’s Allowable Uses Chart, Check All that Apply)
q  Acquisition
q  Creation
q  Preservation
q  Support
q  Rehabilitation/Restoration
Project Summary: Please provide a brief description of the project and how it meets the definitions on the attached DOR Allowable Uses Chart:
Estimated Total Project Budget: Estimated CPA Funding Request:
For CPC Use: Eligible: ______Not Eligible: ______Date of Determination: ______

Beverly CPC DRAFT Project Evaluation Criteria **Revised per October 17, 2013 CPC Meeting Discussion**

Page 2 of 1