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t , <br /> CITY/TOWN APPLICATION FORM Page <br /> .r- <br /> 12. Applicants are requested to submd a list of all projects for all public agencies within the Cornmormeafth for which <br /> the applicant has per#omied or has entered into a contract to perform design services within the five year period <br /> im ediate r preceding the filing of this application. <br /> PROJECT NAME,LOCATION&DESCRIPTION INDICATE YEAR PHASES* REFERENCES <br /> CES <br /> PRCUECT COST(113% comp. NAME AND PHONE <br /> STUDY/DESIGN PEE <br /> In accordance with services authorized, i.e., study (St.), schematics (Sch.), design development (D.D.), <br /> construction documents (C.D.), administration of construction (A.C.)., all phases(All). <br /> . I hereby certify that this firm is a"Designer", as that term is defined in Chapter 7, Section 38A 1.+ of the General Laws, or that <br /> the services required are limited to construction management or the preparation of master plans, studies, surreys, soil tests, <br /> cost estimates or programs. The foregoing is a statement of facts, sworn to by the undersigned under the penalties of perjury. <br /> SSGNATURE PRINTED NAME AND TITLE DATE <br /> EP ADDITIONAL SPACE IS NECESSARY, PLEASE ATTACK ADDfTKDNAL 8 1/2 x 11 SHEETS. <br /> 1 - <br />