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State:________________________________ Jurisdiction:__________________________

Date submitted to State:__________________ Date approved by State:_________________


(1) Application meets the Federal definition of local government and has the authority to enforce acceptable

legislation for the designation and protection of historic properties. _________

(2) Applicant has established a historic preservation review commission consisting of __ members. This

meets State procedure requirements for number of members. _________

There are __ lay members.

There are __ professional members qualified in the fields of

____________________, _____________________, ____________________,

_____________________, ____________________, _____________________,

This meets State procedures requirements for professional membership _________

(3) All commission members have a demonstrated, positive interest, competence, or knowledge in historic

preservation. _________

(4) Professional members of the commission have been appointed to the extent available in the community, and

we have reviewed resumes that document professional qualifications acceptable under the Secretary of the

Interior's Historic Preservation Professional Qualification Standards. If not, the applicant satisfactorily

documented an adequate search for the requisite professional members and how it will obtain access to

expertise when needed. _________

(5) The role and responsibility of the local government have been specified in detail in the enclosed agreement, including:

A. The four basic responsibilities:

1. Enforcing State or local legislation for the designation and protection of historic resources _________

2. Maintaining a system for survey and inventory of historic properties. _________

3. Provide for adequate public participation in the historic preservation program.


4. Reviewing National Register nominations through a qualified local commission.


B. Additional responsibilities:

1. Required of all CLGs in Maine:

a. Maintain adequate financial management systems. __________

b. Adhere to all requirements of the Historic Preservation Fund Grants Manual.


c. Adhere to any requirements mandated by Congress regarding use of federal historic preservation funds. __________

d. Adhere to requirements outlined in the Guidelines for the Certified Local Government Program in Maine. __________

2. Attachment requirements.

a. Letter of request for certification from the chief elected official, including assurances that CLG requirements will be met. __________

b. A copy of the historic preservation ordinance as adopted by the governing body.


c. A clearly defined map indicating the location of any historic resources already identified, including boundaries of any district or districts, and a list of all properties. __________

d. A sample notice of public meetings of the commission (if available).


e. A sample copy of an agenda and minutes of a commission meeting (if available).


f. A sample notice to an applicant of a decision of the commission. __________

g. A copy of the rules of procedure of the historic commission. __________

(6) The CLG contact person, including title/position, mailing address, and telephone number. __________

(7) The Certification Agreement has been signed by SHPO and Chief Elected Local Official. __________

(8) Any other information relevant to this application:





Name and Title