36-284 (5) INITi4wrlctl 20 IE I'fT4T. 111 110 IDMI 11M MU Ce.FlarAls
AS PART OF `lIIE P0-4-= PROCL'SS
1. Vendor Name Commonwealth Community Services
2. Vendor Address 1 Roundhouse -Plaza, Northampton, MA
3. Vendor Telephone # ( 41 3 ) 586-7424
4. Vendor r^..jecutive Director Terrance Blanchard
(or person with administrative responsibility)
5. Address of Group Dwelling Unit
6. Telephone # at Group Dwelling Unit ( 413 ) 586-1592
7. Name of Group Dwelling Unit Program Director Scott Weber
(on site)
8. Number of Residents to be Served at.Group Dwelling Unit Four
(maximum number)
9. Compliance Category for Which Certification is Being Sought: A B C
(Circle One)
10. Ccarpliance Option for Which Certification is Being Sought (within category
selected above)
11. Certification is Being Sought for Additional Group Dwelling YES NO
Units Within the Same Building.
If yes, state address
12. lAcense # of Construction Supervisor (if applicable) X4017'7
NOM: Reapplication is required if a more restrictive Ccnpliance Category is
necessary due to changes in client classification.
NOTE: A building permit may be required.
NOTE: /A//-//4 1- fee of Seventy-Five dollars will be required for the
Certificate of Inspection per unit.