Application for Permit to Restore and Reproduce Gravestones

Form 1 Application for Permit to Restore & Reproduce Gravestones (See detailed instructions) Organization Date Address Contact Phone Cemetery Location Owned or Controlled by Size Earliest Gravestone Landmark (Yes) (No) Before 1885 Designated Cemetery Condition Proposed Work: (General Cleanup) (De-soil) (Replant) (Clean Stones) (Repair Stones) Other City or Town Acceptance of enabling Act, St. 1973, c. 272, § 73A Date Project approval, Coordination, and Participation: City or Town Historical Commission Owner Technical Assistance From 41.02: continued Form 1. (continued) Project Funded by Total In Hand Contributions From Total Project to Start Completion Date Attachments (1) Description of organization, including membership, governance, non-profit status, etc. (2) Statement of Historical significance of Cemetery. (3) Statement of Acceptance and Approval of Project by Owner or Controlling Agency such as Town, Council, etc. (4) Statement of Work Plan and Financial Plan and Budget. (5) Listing of Local Resource People and their Part in Project. (6) Statement from School Systems Indicating Role of Schools and Students in Project if any. (7) Official Statement of City or Town Acceptance of the Enabling Act Allowing Restoration. (8) Statement from Supporting Agencies Indicating Extent of Financial Support, Real or in Kind. Official Use Only Approval: Organization Project Resources Competence Coordination Approved Secretary of the Commonwealth DIRECTIONS FOR COMPLETING APPLICATION FORM Organization: Give name of applicant organization Contact: Name of person to contact concerning proposal Cemetery: Give name of cemetery Size: Give dimensions of cemetery 41.02: continued Owned or controlled by: Give name of owner of cemetery or town agency that has authority to provide access and approval for restoration project Earliest gravestone: Give earliest known or recorded date Before 1885: Total number of stones dated before 1885 Designated landmark: Is cemetery a designated landmark of the Mass. Historical Commission, (yes) (no) Cemetery condition: Indicate whether cemeteryis abandoned, overgrown, vandalized, etc. and how many stones are broken or missing Proposed work: Circle all restoration tasks you are planning to undertake City or town acceptance of enabling act: city or town must give date of acceptance Project approval: Indicate by check mark which agencies have approved project Project funded by: Give name of agencies, foundations, or persons providing funds and give total Technical assistance: Give name of persons or organization who will provide technical assistance to project In kind contributions: List agencies, organizations, or individuals making substantial in-kind contributions (sweat equity) to project and estimated total value