Fair Wage Compliance Certificate CPC grantee
Fair Wage Compliance Certificate
Grantee Information Please Print Legibly_
Project Name: _________________________________________________
Business/Organization Name: ___________________________________________________________
Address: ______________________________________________________
City/State/Zip: _________________________________________________
Phone #: ______________________________________________________
The Northampton Community Preservation Committee requires certification of compliance with wage and hour laws prior to issuance of contracts involving CPA funds. Each grantee must certify
that they are not subject to a federal or state criminal or civil judgment, administrative citation or final administrative determination resulting from a violation of M.G.L. c149,
c150, or the Fair Labor Standard Act. Any grantee who does not certify to the above may be required by the City of Northampton to provide a wage bond or insurance prior to issuance
of a contract for CPA-funded work. Grantees shall obtain from any general contractor or construction supervisor a Fair Wage Compliance Certification and shall require that such general
contractor or construction manager obtain such Certification from each subcontractor on the project. These certifications shall be provided to the CPC.
Grantees / contractors must check box 1 or box 2 as applicable and must sign this Form, certifying compliance with the requirements set out in this Form.
This grantee/contractor is not subject to a federal or state criminal or civil judgment, administrative citation, order or final administrative determination resulting from a violation
of G.L. c. 149, c. 151, or the Fair Labor Standards Act within the last five years.
This grantee/contractor is subject to a federal or state criminal or civil judgment, administrative citation, order or final administrative determination resulting from a violation of
G.L. c. 149, c. 151, or the Fair Labor Standards Act within the last five years. This grantee will provide a wage bond or wage insurance for the period of the contract.
________________________________________ ______________________________
(Typed or printed name of person signing) Signature
________________________________
Date