APPLICATION VERSION V 2.4.8db(02.26.16) FORM: DOE-001 Parent Land Temporary WELCOME FORM STATE PROJECT# : 4550-050-17-1000 0 4550-050-17-1200 Feasibility Emergent 0 0 Welcome to the NJDOE's School Facilities Project Application with Guidance Documents Before using this application, read the various steps outlined on sheet entitled "Process-010" 1 Provide Basic District Information: 6 A. Select County: B. Select District: County Name: UNION County Code: 39 District Name: ROSELLE PARK BORO District Code: 4550 School Name: Roselle Park High School 050 School Code: Current District Aid% (DAP): 48.88% State Share Funding%: 0.00% To Obtain a State Project Number: To obtain a State Project Number: (1) Complete Welcome Form-001; Transmittal Form-100A or B; & Project Application Form-120 or Pre-Development Request110; (2) email app. to Project_App@doe.state.nj.us For DOE Use Only (N## = New or Replacement Schools) (X## = Non-Ed. Facility Or Other Facilities) Project Assignment: 27-Jan-17 Date: DOE Manager: Tom Lakavitch (Private schools have even Cty Codes) Land Project 1100 Temporary Facilities 1200 1400 Emergent Projects Private Schools 1010 Phone: (609) 943-5879 Type of District: SDA District 55% and over District Aid %  Regular Operating District Private School for Disabled Level II CHECK BOX BELOW and explain, if other category(s) apply: Other: If SDA District - explain scenario: This Appl'n submitted by SDA; work performed by A/E who was hired by the SDA to perform work on behalf of School District. This Appl'n submitted by School District personnel Requesting Pre-Development services to be performed by SDA. This Appl'n submitted by A/E who was hired by the District under 13A Grant. This Appl'n submitted by A/E who was hired by the District, for Other Capital Project 7 Components of the Project: 2 Check all components that apply: a) Type of Project (if "Pre-Development Ap," see Item 4 below): School Facilities Project Other Capital Project (no state funding) Emergent Project 8 Explanation/Uses of Forms Pertinent to this Request or Application: Notes ( a  indicates signature(s) required on this form) District or A/E use: Review carefully for critical information & assistance, including funding possibilities District or A/E use: Review carefully for critical info. Welcome: Required with All Project Applications ("Project Apps") and all Pre-Develop't Requests ("Pre-Dev't Reqs") Use Transmittal 100A or 100B: Required with All Project Apps Form N/A Index-002 N/A Process-010 S/F/C 001 School Facilities Project Requested as Demonstration Project Land Acquisition Disposal of Land Request Closing of School Facility Request Energy Service Project b) New Construction Component (if applicable): New School (if also Land Purchase, see also 2d below) Replacement School (w/ disposal/demolition of existing school) New Wing or Bldg Add'n, and/or Partial Demolition/Replacement Acquisition of Existing Educational Facility Acquisition of, Construction of, or Add'n to a Non-Educ'l Facility c) Renovation/Alteration Construction Component (if applicable): Educational: Alteration of any educational space Non-Educational: Impacts only Non-Educ'l space/system/site Educational: Change-of-Use that requires Alterations, or that requires Mech. or Elec. changes per NJAC 5:23 or NJAC 6A:26. Site or Facility Change or other Alteration For Barrier Free, per NJAC 5:23, Sec. 504 of Federal Rehabilitation Act and ADA Act. (This Project Requires Final Ed. Adequacy Review & Review Fee) S/F/C 100  S/F/C 120 Project Application: Required for all Project Applications (NOT PreDevelopment Request.) Various Project Submission Checklists - Your guide to exact submission requirements. For all Project Aps. Project Schedule. Required for all Project Aps DOE Final Review Fee Schedule - BOTH schedule & Fee are Required with ALL Final [Educational] Project Aps S/F/C 121 S F 122 123 S or F 124  S S/F 126 130  S/F 131 C C C C 170 171 172 173 Request for Local Release of Plans Form - required when UCC review of Project is requested to be undertaken by Local Code Official. Applies to Non-SDA managed projects only Temporary Facilities Checklist - for any Temporary Space Project Cost Estimate Summary Form [For both New Construction or Rehabilitation] - Required for all Project Aps Rehabilitation Detailed Cost Estimate Form [Rehab Only] Required in addition to DOE-130 for All Rehab Projects d) Land Acquisition Component (if applicable): Acquire new site or additional parcels to expand an existing site e) Temporary Space Component (if applicable): For Educational Purposes For Non-Educational Purposes (This Project Require Final Ed. Adequacy Review & Review Fee) 3 Phase of this Project Submission (Pre-Dev't Apps-See #4): To Request a State Project # Final Submission Project Close-out Schematic Submission Update to Existing Application Other: NOTE: Once assigned, the State Project # must show on all DOE Forms or project application will be rejected! 4 5 Applicant is requesting these, also: Request for Educational Variance Request for Amendment to District's Approved LRFP Request for Change Order Request for Pre-Development Services Is Project or Pre-Development Request consistent with District's Approved LRFP? If "No," submit an "Amendment Request Form," found at http://www.nj.gov/education/facilities/lrfp/ under separate cover as instructed. Yes No LRFP not Required KEY: Payment Voucher Form - For non-grant projects only Contract Procurem't Compl. Cert. - For non-grant projects only List of Executed Contracts Form - For non-grant projects only Constr'n Plan Compl. Cert. Form - For non-grant projects only     I Form required at Project Initiation (Request for SP#) S Form required at Schematic Project Ap Submission F C Form required at Final Project Ap Submission Form required at Close-out For Additional Information - Click on DOE link at top of sheet! WELCOME FORM, PAGE 1 OF 3 Version 2.4.8db(02.26.16) APPLICATION VERSION V 2.4.8db(02.26.16) STATE PROJECT#: 4550-050-17-1000 FORM: DOE-001 CONTINUED Land Temporary Feasibility Emergent Essential Details: 0 4550-050-17-1200 0 0 9. More Project and Contact Information: Project Title: Project Street Address: Lot / Block: Municipality: Zip Code: District Contact: Contact Title: Contact Telephone #: Contact Fax #: Contact E-Mail: Temporary Classroom Unit at Roselle Park H 185 West Webster Avenue Roselle Park, NJ 07204 A/E Firm: A/E Contact & Title: A/E Telephone #: A/E Fax #: A/E E-Mail: DiCara Rubino Architects Jake Sentschak 973-256-0202 973-256-0227 jsentschak@dicararubino.com To be Completed by SDA for SDA-Managed Projects Only: SDA Division: SDA Contact: SDA Phone #: SDA Fax #: SDA E-Mail: Susan Guercio Business Administrator 908-245-2103 908-245-1226 sguercio@rpsd.org 10. Brief Description of Project: Provide new Temporary Classroom Unit and all associated equipment. 11. Detailed Scope of Work (including list of program spaces proposed to be constructed new or renovated for existing schools): 12. Estimated New Construction: Gross Square Feet 13. Referendum Information, if applicable: January (4th Tuesday) March (2nd Tuesday) April (3rd Tuesday) Proposed Year: September (Last Tuesday) December (2nd Tuesday) None 14. APPLICATION FOR GRANT FUNDING Complete this section only if you are a Regular Operating District requesting consideration for grant funding. The previous process for grant funding allocations has changed significantly. For a school facilities project to be considered for grant funding, the proposed scope of work must be 100% eligible for State support and be included in one of the priority “levels” described in Section 12B. If the project scope is not 100% eligible for State support and/or the scope of work is not included in one of the three prioritization levels, the project will not be considered for grant funding. However, a district may request debt service aid if the proposed scope of work, or a portion of the proposed scope of work, is eligible for State support.Please review the grant funding information available on the Office of School Facilities web page at http://www.nj.gov/education/facilities for additional information, including the application process, eligibility, and critical deadlines. A. Grant Funding Priority Levels and Proposed Scope of Work: Indicate the proposed project scope of work in accordance with the three grant funding prioritization levels. If the proposed scope of work is not applicable to any of the prioritization levels and/or is not 100% eligible for State support, the project does not qualify for grant funding. If the project has work applicable to more than one level, the project will be prioritized in the lower level. Please note that the Department will not confirm the district's priority level selection or make a final determination concerning priority level prior to grant approval or rejection notification. LEVEL ONE Critical capital maintenance needs and program mandates Upgrades to essential building systems (Structural, HVAC, electrical, plumbing systems; Includes required refinishing work.) Building skin (Repair or replacement of roof, windows, masonry, etc.) Building code issues ADA upgrades (incl. site and building access, toilet room renovations.) Hazardous materials abatement Security and communications systems (incl. essential systems such as public address, telephone, security; Excludes program space relocation.) Site drainage (To remediate an existing problem; Not in conjunction with new construction.) Elementary school playgrounds (Upgrades to existing playgrounds only; Not applicable for new playgrounds.) Renovated or new early childhood classrooms (See Grant Funding Guidelines at http:/www.nj.gov/education/facilities) Special population needs (See Grant Funding Guidelines at http:/www.nj.gov/education/facilities) LEVEL TWO Renewal of existing buildings, overcrowding, and improving quality of instructional spaces Repair/replacement of existing building systems and components not included in Level One. Existing site upgrades, excluding athletic fields and tracks (incl. upgrades to paving, sidewalks, fencing, security lighting) Renovation and/or new construction of capacity-generating classrooms (Must pertain to at least 75% of impacted square feet) Technology infrastructure upgrades (Per Department's Technology Plan; Does not include equipment) WELCOME FORM, PAGE 2 OF 3 Version 2.4.8db(02.26.16) APPLICATION VERSION V 2.4.8db(02.26.16) STATE PROJECT#: 4550-050-17-1000 FORM: DOE-001 CONTINUED Land Temporary Feasibility Emergent 0 4550-050-17-1200 0 0 14. CONTINUED LEVEL THREE Major school facilities projects involving renovation and new construction Projects will be ranked in accordance with various educational criteria. Grant allocations will depend upon demand. Renovation and/or new construction project (Proposed new square feet must be 100% eligible for State support.) General Description: Proposed Grades: B. Proposed Funding of Local Share: Select one below. (Status of local share does not impact grant eligibility or prioritization.) Pending referendum (Complete Item 13 on page 2.) Local share funded in current budget. Local share to be funded in next budget. 15. District, BOE and A/E Contact Information (THIS MUST BE COMPLETED FOR ALL PROJECTS): District Chief School Administrator: Pedro Garrido Name: 908-245-1197 Phone: 908-245-1226 Fax: pgarrido@rpsd.org Email: CSA Mailing Address: 510 Chestnut Street Roselle Park, NJ 7204 A/E Firm Mailing Address: DiCara Rubino Architects 30 Galesi Drive Wayne, N.J. 07470 16. District Business Administrator: Susan Guercio Name: 908-245-2103 Phone: 908-245-1226 Fax: sguercio@rpsd.org Email: BA Mailing Address : 510 Chestnut Street Roselle Park, NJ 7204 District Board President: Chris Miller Name: 908-245-2103 Phone: 908-245-1226 Fax: cmiller@rpsd.org Email: Bd. Pres. Mailing Add's : 510 Chestnut Street Roselle Park, NJ 7204 IN THE CASE OF A PRIVATE SCHOOL FOR THE DISABLED: "Chief School Administrator" shall be the Executive Director & BOE shall be the Board of Trustees, & All Projects shall be "Other Capital" and include all requirements for an "Other Capital" Project - except these items are not required: Cohort-Survival Enrollment, Room Inventory, and Feasibility Study. Send electronic files to DOE at the following email address: project_app@doe.state.nj.us NOTE: THIS ELECTRONIC APPLICATION MUST BE E-MAILED TO DOE IN ADVANCE OF ANY "PAPER" PROJECT APPLICATION SUBMISSION. ANY SUBSEQUENT CHANGES TO THE APPLICATION MUST ALSO BE TRANSMITTED ELECTRONICALLY. WELCOME FORM, PAGE 3 OF 3 Version 2.4.8db(02.26.16) FORM: DOE-002 V 2.4.8db(02.26.16) Click for Hyperlinks to nonDOE Info STATE OF NEW JERSEY DEPARTMENT OF EDUCATION - CHIEF OF STAFF OFFICE OF SCHOOL FACILITIES INDEX OF ALL FORMS & THEIR USES Form: 001 Title/Description: WELCOME FORM 000 Series Forms This form gathers general information about the project type, scope, and special characteristics and helps you understand what other forms and types of information will be required by the DOE to process your application in a timely manner. Form 121 has complete checklists. 100A/B TRANSMITTAL FORM 100A Choose A or B. These forms require signature(s) and MUST accompany ALL "paper" submissions to DOE. 100 Series Forms 110 110 Series Forms This form is to be submitted by all districts required to use SDA when requesting pre-development services, and is the first step to advance this type of district's school facility project. Remember - this form must be submitted with an authorizing Board Resolution. Use Transmittal Form 100A with this Form. 120 PROJECT APPLICATION 120 Series Forms This form identifies general information about the project type, scope, other special characteristics of a project (including funding sources) and is to be submitted with all project applications to the DOE, regardless of project type. 121 SCHOOL FACILITIES PROJECT SUBMISSION CHECKLIST Various Checklists outlining project submission requirements for various project types. N.J.A.C. 6A:26-3.2, 5.2, 5.3, 5.4 & 7.1 122 PROJECT SCHEDULE FORM This form is required for all Project Aps, and will assist the District in scheduling projected milestones with consideration of DOE required timelines for review and approval. DOE will review the schedule for any necessary revisions. N.J.A.C. 6A:26-5.3 123 FINAL EDUCATIONAL REVIEW FEE SCHEDULE The final review fee for education adequacy review is required for ALL projects requiring educational review. Note that the fee will be based on the total estimated construction cost as presented in the approved “Project Cost Estimate Form 130” at the time of FEC approval. N.J.A.C. 6A:26-5.5. 124 REQUEST FOR LOCAL RELEASE OF SCHOOL CONSTRUCTION PLANS This form is required when the District requests to have the local code enforcing agency review plans for code compliance. This form is to be executed by the District and the local code enforcing agency and submitted to DOE at the Final Project Submission. (Authority projects must use DCA) N.J.A.C.6A:26-5.4(b). DOE will transmit the Request Form with an approved set of plans to DCA. DCA will determine if the local code enforcing agent selected by the district is qualified to review the plans. For Private Schools for the Disabled, DOE will review and approve the Request for Local Release of Plans. 125 EDUCATIONAL VARIANCE APPLICATION AND CHECKLIST This form shall be executed by the District and must be submitted to DOE if a deviation from an educational adequacy requiremnt is being requested by the District. N.J.A.C. 6A:26-6.3 (c) 126 TEMPORARY FACILITIES APPLICATION AND CHECKLIST Applies only in the case that Temporary Facilities (TCU, temporary lease of space, etc.) are being initiated in association with a school facilities project or independently. N.J.A.C. 6A:26-3.2, 3.14, 5.2, 5.3, 5.4, 7.1 & 8.1 130 130 Series Forms This form is required for all projects. The total estimated project construction cost (at time of FEC approval) will be used in determining the final review fee (if applicable). Cost Estimate is to be the estimated actual costs for both New Construction and Rehabilitation. N.J.A.C. 6A:26-5.3. 131 DETAILED REHABILITATION COST ESTIMATE FORM This form is required [in addition to Form 130] for all projects with a Rehabilitation/Renovation component. The estimated rehabilitation construction cost information is transferred to the 'Summary Cost Estimate Form' DOE-130. Forms DOE-130 and 131 are required to be submitted together when rehabilitation is a component of a project. LRFP AMENDMENT REQUEST DOE Office of School Facilities Website The proposed project must be included in an approved LRFP per N.J.A.C. 6A:26-2.3(c). To amend an approved LRFP, see instructions found on the Department's Office of School Facilities website at http://www.nj.gov/education/facilities/lrfp/. To initiate an amendment, the disitrict must submit the Amendment Request Form and a Board of Education This form is designed to be used as an administrative tool to assist DOE in identifying changed reports and expediting the amendment review process. INDEX OF ALL FORMS & THEIR USES: Page 1 of 2 Version 2.4.8db(02.26.16) FORM: DOE-002 V 2.4.8db(02.26.16) Click for Hyperlinks to nonDOE Info STATE OF NEW JERSEY DEPARTMENT OF EDUCATION - CHIEF OF STAFF OFFICE OF SCHOOL FACILITIES INDEX OF ALL FORMS & THEIR USES Form: Title/Description (CONTINUED…): 150 LAND ACQUISITION APPLICATION AND CHECKLIST 150 Series Forms This is an additional checklist for land acquisition projects, when stand-alone or part of a project. N.J.A.C. 6A:26-7.1 151 DISPOSAL OF LAND APPLICATION AND CHECKLIST This is an additional checklist for Disposal of Land projects, when stand-alone or part of a project. N.J.A.C. 6A:26-7.4 152 CLOSING OF SCHOOL FACILITY APPLICATION AND CHECKLIST This is an additional checklist for School Closure projects, when stand-alone or part of a project. N.J.A.C. 6A:26-7.5 160 SCHOOL CONSTRUCTION AND RACIAL/ETHNIC ENROLLMENT QUESTIONNAIRE 160 Series Forms This form is required for all projects in accordance with Federal regulations including (but not limited to) any project in which educational spaces are changed, or projects which include land and/or building acquisition. N.J.A.C.6A:26-5.3(c). 170 PAYMENT VOUCHER FORM For Non-SDA Grant Projects only 170 Series Forms This form is for non-grant projects and is to be executed by the District and consultants prior to paying any Vendor. N.J.A.C. 6A:264.7(b). Districts choosing a grant as state funding source shall use the SDA Request For Disbursement Voucher. This form must be retained in the district project file. 171 CONTRACT PROCUREMENT COMPLIANCE CERTIFICATION For Non-SDA Grant Projects only This form is for non-grant projects whenever a design and/or construction contract is awarded. This form is to be executed by the District Business Administrator and approved by Board Resolution. N.J.A.C. 6A:26-4.7. Districts choosing a grant as state funding source shall use the SDA Form of Contractor Certification and Consent upon award of contract. 172 LIST OF EXECUTED CONTRACTS For Non-SDA Grant Projects only This form is for non-grant projects and is to be executed by the District. 173 CONSTRUCTION PLAN COMPLIANCE CERTIFICATION For Non-SDA Grant Projects only This form is for non-grant projects. This form is to be executed by the District Business Administrator and approved by Board Resolution. It certifies that the project was constructed in compliance with the approved plans and specifications. N.J.A.C. 6A:264.7(b). Districts choosing a grant as state funding source shall use the SDA Certification by School Business Administrator and SDA Design Consultant Certification Upon Final Completion Forms. 174 CHANGE ORDER REQUEST FORM This form to be executed by the District, A/E, District Board Secretary and submitted to the DOE per N.J.A.C. 6A:26-4.9 et seq. To Access Downloadable Forms: This Project App is a MS Excel file available at the following url (Download a new file for each application): http://www.state.nj.us/njded/facilities/projectapplication/ Various Long Range Facility Plan (LRFP) forms can be downloaded from the DOE, Office of Facilities website at the following url: http://www.state.nj.us/education/facilities/lrfp/ To Access Other Relevant Sites: New Jersey's gas and electric utilities have teamed up to offer commercial and industrial customers an extensive array of services and incentives to improve construction, renovation and equipment upgrade projects! Click on the SmartStart® Logo to learn more about this unique, statewide energy-efficiency program! ONE STOP is a total facility approach; a coordinated permitting and compliance assistance process. A permittee can now turn to one source to identify all permits required for a development or significant facility start-up or expansion project and maintain consistent contact throughout the process. This process will allow the Department to provide better customer service to the public and regulated entities. NJDEP ONE STOP PROCESS Click on the NJDEP-ONE STOP Logo to learn more about this helpful guidance program! Schools Development Authority (A Subsidiary of EDA) maintains a website posting of current school construction information including project status, bidding information, forms, guidance, and other Click on the SDA Logo to connect with Schools Development Authority Website! Back to Top of Page Leadership in Energy and Environmental Design (LEED) Green Building Rating System™ is a voluntary, consensusbased national standard for developing high-performance, sustainable buildings. Members of the U.S. Green Building Council. Click on the LEED Logo to learn more about LEED. INDEX OF ALL FORMS & THEIR USES: Page 2 of 2 Version 2.4.8db(02.26.16) FORM: DOE-010 V 2.4.8db(02.26.16) STATE OF NEW JERSEY DEPARTMENT OF EDUCATION - CHIEF OF STAFF OFFICE OF SCHOOL FACILITIES PROJECT SUBMISSION PROCESS OVERVIEW -- SEE ALSO THE SEPARATE "DIRECTIONS FOR PROJECT APPLICATION" I. Determine if project requires New Jersey Department of Education (DOE) review: a. District is to determine if project requires DOE submission: All Capital Projects (incl. Capital Maintenance) are required to be submitted to DOE for review and approval. DOE review is not required for "Required" or "Routine" Maintenance Projects intended solely to achieve the design life of a school facility (N.J.A.C. 6A:26 3.2 & 3.3). Also, "Required" and/or "Routine" Maintenance Projects or such project components are not eligible for funding. b. Mandatory Pre-Development Services for Districts required to use the Schools Development Authority (SDA): Prior to an actual Project Application Submission, these Districts shall submit a "Pre-Development Services Request" setting forth all activities (including but not limited to feasibility studies, remediation, site development, design work, acquisition of temporary facilities and acquisition of land) which need to be undertaken prior to submission of a school facilities project application. The District is to fill in the "Welcome Form" (Form-001) and “Predevelopment Services Request and Checklist" (Form-110), with all information and send the electronic file to the DOE to this e-mail address: project_app@doe.state.nj.us. After NJDOE sends back the electronic information with a project number assigned, the District is to send paper copies of all items listed on Form DOE-110 to NJDOE Office of School Facilities accompanied with Transmittal Form 100A. The DOE will review each application for eligibility, consistency with the district's approved LRFP, and, if approved, the request will be forwarded to the SDA which shall undertake such activities, or the SDA may, in its discretion, delegate portion or all predevelopment activates to be undertaken by the district . N.J.A.C.6A:26-3.9(d) II. If the District determines that the proposed project requires DOE review, the District/SDA shall pursue the following steps: Step I-Project Initiation: A. The District is to fill in the "Welcome" (Form-001),and “Project Application” (Form-120) with ALL information and send the electronic file to the DOE to this e-mail address: project_app@doe.state.nj.us. If upon initial review the project qualifies as a capital project and is consistent with the district's LRFP (or if a LRFP amendment is proposed), the DOE will return the electronic file after assigning a State Project Number (aforementioned procedure II.A can be skipped if project # was already obtained via Predevelopment Request). B. Then the District is to complete all requisite forms of the workbook, print all applicable forms, obtain required signatures, and gather hard ("paper") copies of signed forms with other items being submitted to DOE (drawings, ed. specs, etc.). District must submit a completed electronic application file to the DOE prior to submitting the paper submission of a project application WITH TRANSMITTAL FORM 100A OR 100B (AS APPLICABLE). Step II-Preparation of "Paper" Project Application (For Districts required to use the SDA: Projects MUST come to DOE via SDA): The District/SDA is to carefully review all applicable checklists for required submission items. Every Project Application package is to be topped with a Transmittal Form DOE-100 A or B prior to being sent to DOE. ALL PLANS MUST BE FOLDED! also: ALL Paper Project Application Submissions received without a Transmittal Form Step III-Forward the Project Application Package to DOE (1 copy of all application forms & checklists): Send the package to the attention of the reviewing DOE Manager to the following address: (Remember: MUST have Transmittal Form DOE-100A or DOE-100B; All printed forms must show the assigned State Project Number pre-populated into box at top of each form) Mail: New Jersey Department of Education Courier/Express Mail: New Jersey Department of Education Division of Education System Efficiency Division of Education System Efficiency Office of School Facilities Office of School Facilities P.O. Box 500, Trenton, N.J. 08625-0500 200 Riverview Plaza, 2nd Floor, Trenton, N.J. 08625 Step IV-DOE Review Process: 1) When received at the DOE, the QC Unit or other personnel will review it to see if all required documents are included in the application. Once all required documents are received, the project folder will be assigned and forwarded to a Manager for review. 2) If the project qualifies as a school facilities project, is consistent with the approved LRFP, meets educational specifications and schematics requirements if applicable, is consistent with the FES/District programmatic model, the District will receive a letter from DOE approving the project and determining preliminary eligible costs (PEC) of the project. For districts required to have the SDA to construct the project, the DOE will instead transmit a preliminary project report with project and cost information to SDA. 3) If the project does not meet the standards of (2) above, the DOE will notify the district, indicating the reason(s). If the district resubmits/revises the project and remedies the deficiencies, the DOE will then send a letter to the district approving the project and determining PEC of the project. 4) All districts receiving a DOE school facilities project approval/PEC must respond to the DOE determination within 30 days (see (6) below) relative to the PEC and any space inconsistent with either the FES or programmatic model (e.g., request additional space eligible for State support). Absent such notification, the DOE may assume district agreement with the parameters of the PEC/Approval letter that was issued. Districts not required to use the SDA to construct a school facilities project have 30 days of the date of the school facilities project approval/PEC letter to notify the DOE of the following additional elections: (i) district or SDA to do the construction, (ii) if district, State support funding through debt service aid or grant, and (iii) acceptance of or deferral of decision on PEC. The above information is to be submitted to the DOE with a board resolution signed and sealed. For districts electing or required to have the SDA construct a school facilities project, the DOE will prepare a preliminary project report with project and cost information for the SDA. Districts notifying the DOE of deferral of a decision on PEC, may appeal the PEC within 30 days of the preparation of detailed plans and specifications by a design professional, for an increase in the PEC. PROJECT SUBMISSION PROCESS OVERVIEW Page 1 of 2 Version 2.4.8db(02.26.16) FORM: DOE-010 V 2.4.8db(02.26.16) STATE OF NEW JERSEY DEPARTMENT OF EDUCATION - CHIEF OF STAFF OFFICE OF SCHOOL FACILITIES PROJECT SUBMISSION PROCESS OVERVIEW -- SEE ALSO THE SEPARATE "DIRECTIONS FOR PROJECT APPLICATION" Step IV-DOE Review Process (continued…) 5) Districts not required to use the SDA nor electing the SDA to construct their projects, whose PEC is either accepted or decided on appeal, will receive a letter from the DOE calculating final eligible costs (FEC). Establishment of FEC is required prior to referendum in all cases. For districts using the SDA to construct their projects, SDA will determine, based on detailed plans and specifications, whether the school facilities project can be completed within PEC. If the answer is yes, the DOE will notify the district that PEC equals FEC. If the answer is no, the SDA will consult with the district and the DOE, and make a cost recommendation to the DOE that may include changes to the project or an increase in eligible costs of the project. The DOE will then notify the district of FEC and issue a final project report with project and cost information to the SDA. 6) Local support (if required): A district may not seek voters' approval of the local support (e.g. school bonds, capital reserve, lease purchase, etc.) for the school facilities project until the DOE has notified the district of the FEC for the project. No school facilities project may be constructed unless, if there is a local support amount, such local support has received voters approval as set forth in N.J.A.C. 6A:26-3.7. However, where a district is not using the SDA, it may seek approval of the estimated local share in its annual budget prior to a determination of FEC. 7) Grant Agreement (Section 15): For those districts which are not required to use SDA to construct their projects and which chose State share in the form of a grant, the DOE will forward a copy of the Approval Letter, the FEC letter, and SDA transmittal letter to SDA. The district will then be contacted by SDA to start the process of submitting for a Section 15 grant agreement. 8) Preparing the Final Submission: Any district advancing a Capital Project that affects educational adequacy must apply for final approval of the educational adequacy of the project. In the case of a SDA school facilities project, the SDA alone may apply to DOE on behalf of the district. If district is not using SDA to construct, and requests to have the local code-enforcing agency review the project, a completed Request for Local Release of School Construction Plans DOE-124 shall be submitted to the DOE at the final submission phase. The DOE will forward this request to DCA for review and approval. The Applicant will be notified directly by DCA if the request has been approved. NOTE: The full amount of any DOE Review Fee is required at the FIRST PHASE of an application for Final Educational Review. Step IX-Bid Award and Construction (not to occur until all DOE & UCC approvals are granted and all local/State funding secured): During Bid Award for ROD Grant Projects, the District is required to submit: a. Form DOE-171, Contract Procurement Certification shall be used by non-SDA grant projects. This form shall be executed by the district and maintained in the project file and submitted to DOE as part of project close out documents. During Construction of ROD Grant Project, the District is required to submit: a. Form DOE-170, Payment Voucher, shall be used by non-SDA Grant projects. This form shall be used by the district during the life of the project or a similar form that includes the same information. Final Payment Voucher shall be submitted to DOE as part of project close out documents. During Construction of ROD Projects, the District is required to submit: a. Form DOE-174, Change Order Request Form, is to be submitted to the DOE for review and approval as defined in N.J.A.C. 6A:26-4.9. During Construction of SDA School Facilities Project, SDA is required to submit: a. Change orders that affect the approved number, size, configuration, location or use of educational space shall be submitted to the DOE for review and approval regardless of the amount. N.J.A.C.6A:26:4.10 b. SDA will submit to the DOE periodic reports on each project being constructed under its auspices, indicating the contract award amounts, the nature and scope of each approved change order, the revised project amounts and the total costs of change orders approved to date (N.J.A.C. 6A:26-4.10). Step X-Project Close-out: At the completion of every Authority and Non-Authority School Facilities Project, the DOE requires the District or the Authority to submit the Close-Out submission requirements per Form DOE-121, School Facilities Project Submission Checklist. IMPOTANT NOTE FOR SDA DISTRICT REQUESTING DEPARTMENTAL APPROVAL FOR AN OTHER CAPITAL PROJECT: SDA districts may apply for an Other Capital Project application, but prior to assigning a State Project Number the Office of School Facilities will require the district's DOE Budget Manager approval of the inclussion of the project costs in the district's current budget. The Budget Manager's decision will be based on whether the project can be funded under the Act or not. PROJECT SUBMISSION PROCESS OVERVIEW Page 2 of 2 Version 2.4.8db(02.26.16) Submitting which project? V 2.4.8db(02.26.16) (You MUST check one) TRANSMITTAL FORM 100A FORM DOE-100A Use for Projects in Regular Operating Districts And Districts Requesting Predevelopment Services Parent Land Temporary Feasibility Emergent STATE PROJECT#: 4550-050-17-1000 4550-050-17-1200 ***THIS FORM TO ACCOMPANY ALL "PAPER" SUBMISSIONS TO NJDOE for Non-SDA Projects & Predevelopment Requests*** Project and District Information County: District Name: District Number: School Name: School Code: UNION / 39 ROSELLE PARK BORO 4550 Roselle Park High School 050 District Contact: Contact Title: District Telephone #: District Fax #: District E-Mail: Project Title: Project Address: Municipality: Zip Code: Temporary Classroom Unit at Roselle Park H 185 West Webster Avenue Roselle Park, NJ 07204 A/E Firm: A/E Contact: A/E Phone #: A/E Fax #: A/E E-Mail: Susan Guercio Business Administrator 908-245-2103 908-245-1226 sguercio@rpsd.org DiCara Rubino Architects Jake Sentschak 973-256-0202 973-256-0227 jsentschak@dicararubino.com Provide a Brief Description of Project: Provide new Temporary Classroom Unit and all associated equipment. THIS TRANSMITTAL IS:  Requesting a State Project Number Ed. Specs & Schematic Submission Final Submission Updating an existing application Predevelopment Service Request AND DISTRICT REQUESTS THAT NJDOE: Review & Approve (This is the 1 st Submission of this type!) Receive for NJDOE Records Only Review/Approve Additional Items @ Request of DOE's QC Unit Review/Approve Add'l. Items @ Request of DOE County Mgr. County Manager Tom Lakavitch Phone # (609) 943-5879 Other: 1. Project Component(s): 2. Submission Includes: (Carried from Essential Details tab)  School Facilities Project  Other Capital Project (no state funding) Emergent Project Community Provider Early Childhood Facility Demonstration Project Land Acquisition Disposal of Land/Building Request Closing of School Facility Request Energy Service Project 3. Note Primary Attachments: (Check all that apply) (Check all that apply) Project Initiation (Request for SP#) Predevelopment Request (SDA Project only) Project Application (Schematic) Final Project Submission Project Close-out Variance Request Change Order Request LRFP Amendment Request Other: Educational Specifications Schematic Plans Final Plans Maintenance Plan Fee (All Final Edu'l Project Aps) 4. Note Other DOE-Forms included with THIS TRANSMITTAL (Check all that apply; Utilize Checklists to verify Requirements!) :  Indicates form/submission is eventually required for this project, based on information you entered on "Essential Details-001" tab 001 FORM: DOE-001   150 LAND ACQUISITION APPLICATION AND CHECKLIST 100A TRANSMITTAL FORM FOR NON-SDA PROJECTS  100B TRANSMITTAL FORM FOR SDA PROJECTS 151 DISPOSAL OF LAND APPLICATION AND CHECKLIST          110 120 121 122 123 124 125 126 130 131 PRE-DEVELOPMENT SERVICES REQUEST AND CHECKLIST  SCHOOL FACILITIES PROJECT SUBMISSION CHECKLIST  PROJECT SCHEDULE FORM  FINAL EDUCATIONAL REVIEW FEE SCHEDULE  REQUEST FOR LOCAL RELEASE OF SCHOOL CONSTRUCTION PL  PROJECT APPLICATION EDUCATIONAL VARIANCE APPLICATION AND CHECKLIST TEMPORARY FACILITIES APPLICATION AND CHECKLIST SUMMARY COST ESTIMATE FORM DETAILED REHABILITATION COST ESTIMATE FORM 152 CLOSING OF SCHOOL FACILITY APPLICATION AND CHECKLIST 160 RACIAL/ETHNIC ENROLLMENT QUESTIONNAIRE 170 PAYMENT VOUCHER FORM 171 CONTRACT PROCUREMENT COMPLIANCE CERTIFICATION 172 LIST OF EXECUTED CONTRACTS 173 CONSTRUCTION PLAN COMPLIANCE CERTIFICATION 174 CHANGE ORDER REQUEST FORM Other: Other: Other: 5. Transmittal Authorization: Transmitted by District Representative/Designee (Print Name) : Transmitted by District Representative/Designee ( Signature ) : Jake Sentschak Date Submitted: 6. Additional Comments regarding Project Transmittal:: 7. District Board of Education Information (THIS MUST BE FILLED OUT IN ALL CASES): District Chief School Administrator: Pedro Garrido Name: 908-245-1197 Phone: 908-245-1226 Fax: pgarrido@rpsd.org Email: District Business Administrator: Susan Guercio Name: 908-245-2103 Phone: 908-245-1226 Fax: sguercio@rpsd.org Email: District Board President: Chris Miller Name: 908-245-2103 Phone: 908-245-1226 Fax: cmiller@rpsd.org Email: Form DOE 100A Transmittal Form Page 1 of 1 Version 2.4.8db(02.26.16) Form-100B V 2.4.8db(02.26.16) (ONLY USE FOR: SDA-Managed Projects) FOR SDA USE ONLY SDA PROJECT TRANSMITTAL TO DOE County: District Name: District Number: School Name: School Code: UNION ROSELLE PARK BORO 4550 Roselle Park High School 050 Date: Project Title: Project Address: Municipality: Zip Code: Temporary Classroom Unit at Roselle Park H 185 West Webster Avenue Roselle Park, NJ 07204 SDA Project Officer: SDA Phone #: SDA Fax #: SDA E-Mail: 1. District Type: Parent THIS FORM TO ACCOMPANY ALL "PAPER" SUBMISSIONS for SDA Projects STATE PROJECT# : 4550-050-17-1000 Land Temporary Feasibility Emergent 4550-050-17-1200 SDA Division: SDA Managed District 2. Category: SDA Managed Project Pre Development Land Acquisition Design & Construction Pre-Development GRANT Submission Type Initial Submission Additional Information 13 A GRANT TCU GRANT 3. Brief Description of Project: Provide new Temporary Classroom Unit and all associated equipment. 4. Project Context: nmbmb.mb.jb. 5. Project Type(s): School Facilities Project Emergent Project (Check All Applicable) 6. Level: New Construction Rehabilitation Level 1 Level 1 Demonstration Project Land Acquisition Level 2 Level 2 7. Requested Pre-Development Scope: Temporary Facilities Site Analysis Acquisition of New Site Temporary Classroom (TCU) Acquisition of Add. Parcels Temporary Leased Space District Owned Land Temporary Leased Facility Acquisition of Temporary Facility 8. Project Scope: New Construction: New Building Addition Replacement Acquisition of Building Energy Service Project Community Provider ECC Level 3 Level 3 Feasibility Study Rehabilitation: Renovation Alterations Pre-Design services: Ed. Spec./Programming Schematic Design Capital Maintenance Rehabilitation w/Building Acquisition 9. Temporary Facilities: The Purpose of the Proposed Temporary Facilities: To House Excess Enrollment-in advance of permanent construction To House Early Childhood students-in advance of permanent construction Swing Space During Construction 10. Attachments to This Transmittal: For SDA Managed Projects: Land Acquisition Approval Request Educational Spec's & Schematic Approval Request Feasibility Study Approval Request Final Educational Adequacy Approval Request Disposal of Land Approval Request Change Orders Request Close out submission Approved Program by DOE: Program Net SF Program Gross SF Grossing Factor Rehab Approved SF Proposed Project by SDA: Proposed Net SF Proposed Gross SF Grossing Factor Rehab Proposed SF Change in Project SF: Increase/Decrease Net SF Increase/Decrease Gross SF Increase/Decrease Grossing Increase/Decrease Rehab SF Statement: The Proposed Net SF is GREATER THAN Approved Program LESS THAN Approved Program N/A GREATER THAN the FES LESS THAN the FES N/A GREATER THAN Approved Scope LESS THAN Approved Scope N/A Explanation: The Proposed Grossing Area is Explanation: The Proposed Rehab Scope is Explanation: Prepared By A/E for PMF: A/E Firm: Date: A/E Contact: A/E Phone #: A/E Fax #: A/E E-Mail: A/E Signoff: Submitted By PMF to SDA: PMF Firm: Date: PMF Contact: PMF Phone #: PMF Fax #: PMF E-Mail: PMF Signoff: Submitted By SDA to DOE: I reviewed this submission for Scope, Budget and Schedule impact. SDA Project Officer Name: Signature: Version 2.4.8db(02.26.16) SDA Regional Director Name: Signature: FOR DOE-110 STATE OF NEW JERSEY DEPARTMENT OF EDUCATION - CHIEF OF STAFF OFFICE OF SCHOOL FACILITIES V 2.4.8db(02.26.16) Parent Land Temporary Feasibility PRE-DEVELOPMENT SERVICES REQUEST AND CHECKLIST STATE PROJECT#: 4550-050-17-1000 4550-050-17-1200 Emergent (Districts required to use the SDA to construct their projects must use this form when requesting Pre-Development Services) County: District Name: District Number: School Name: School Code: UNION ROSELLE PARK BORO 4550 Roselle Park High School 050 District Contact: Contact Title: District Telephone #: District Fax #: District E-Mail: Project Title: Project Address: Municipality: Zip Code: Temporary Classroom Unit at Roselle Park H 185 West Webster Avenue Roselle Park, NJ 07204 SDA Division: SDA Contact: SDA Phone #: SDA Fax #: SDA E-Mail: Susan Guercio Business Administrator 908-245-2103 908-245-1226 sguercio@rpsd.org Brief Description of Project: Provide new Temporary Classroom Unit and all associated equipment. 1. District Type: SDA District 2. Identification of Project(s) from District's LRFP:  Project not consistent LRFP; Requires Amendment Request Provide LRFP Project Number(s): 55% and over District Aid %  Regular Operating District Private School for Disabled Level II LARGE CHECK-BOXES INDICATE REQUIRED ATTACHMENTS; FOR DOE USE ONLY. IN addition to THIS form, provide all of the following: Transmittal Form 100A Welcome Form DOE-001 3. This Request must be accompanied by a Board Resolution: Signed and Sealed Board Resolution approving the submission of the Pre-Development Activities request. ALSO: If the district is requesting the designation of this project as a Demonstration Project, the Resolution must authorize the submission of this request for the designation of this project as a Demonstration Project. (NOTE: State Operated Districts are NOT required to submit Board Resolution) Provide copy of LRFP report that indicates proposed project (new/additions/improvements) are in District's approved Plan. 4. Identify All Requested Pre-Development Activities (Check all that apply, attach submittals) : Provide a written description of all the Pre-Development Services requested by the District. These may include (but are not limited to): I. For SDA Districts only Site acquisition services: required in order to acquire a site for the above referenced School Facilities Project either by purchase or condemnation (such activities to include site identification, site analysis, environmental and other analyses/investigations, survey, title work, appraisals, and the engagement of design consultants and other consultants to prepare any feasibility studies, reports, or site utilization plans required for land acquisition). If District is requesting LAND ACQUISITION, District must provide the following (attach supplemental pages if necessary): Site #1 Block: All Lot #'s: Current Use(s): Owner(s): Site #2 Block: Current Use(s): All Lot #'s: Owner(s): Site #3 Block: Current Use(s): All Lot #'s: Owner(s): Provide Tax Map(s) of all lots in Sites #1 - 3 noted above, with lots and block numbers clearly showing, and subject property indicated. Provide Site Location Map(s) (i.e., USGS Maps or Street Map) for Sites #1 - 3 noted above, with property boundaries indicated. N.J.A.C. 6A:26 7.1-1 ( This requirement for any and all Requests for Approval of Land Acquisition): a) A written request for approval from the district, which shall include a statement, signed by the board president and the chief school administrator, indicating the immediate and ultimate proposed uses of the site, in terms of building use, grade organization and potential maximum enrollment, and whether the land is, or will be, part of a school facilities project indicated in the district’s LRFP; b) Also explain if the Land Acquisition is now, or if it will be, part of a school facilities project. N.J.A.C. 6A:26 7.1-2 (Written Statement from governing local / county water and sewerage agencies indicating the following): a) Land can be adequately provided with the necessary water for the maximum proposed enrollment and use b) Land can be adequately provided with an acceptable sewerage disposal system for the proposed maximum enrollment and use c) Whether the necessary water and/or sewerage infrastructure is, or is not, already in place to service the requirements of the site N.J.A.C. 6A:26 7.1-6 (School district map showing the subject property location and the location(s) of other existing schools/sites). N.J.A.C. 6A:26 7.1-7 (School district map showing proposed attendance area to be served and the number of students). N.J.A.C. 6A:26 7.1-8 (Office of Bilingual Education & Equity Issues [OBE & EI] Racial/Ethnic Enrollment Questionnaire showing impact on racial balance). Provide copy of dated Transmittal Letter indicating form DOE-160 was sent to OBE&EI. N.J.A.C. 6A:26 7.1-15 (Recommendation of the County Superintendent of Schools with regard to the Land Acquisition). FOR DOE-110 - : Page 1 of 2 Version 2.4.8db(02.26.16) FOR DOE-110 Parent STATE PROJECT#: 4550-050-17-1000 Land Temporary 4550-050-17-1200 Feasibility Emergent Pre-Development Service Request (continued..) LARGE CHECK-BOXES INDICATE REQUIRED SUBMISSION DOCUMENTS; FOR DOE USE ONLY. . For SDA Districts, engagement of design consultants or other consultants to prepare the design work [other than site design] (e.g., educational specifications and schematic plans) to develop an application for the above referenced School Facilities Project.) If District is requesting ENGAGEMENT OF CONSULTANTS for Educational or Non-Edu'l Project, District must provide: Copy of the Proposed Room Inventory Report from the LRFP Copy of a New Proposed Programmatic Model (DOE's " *.xls ") ONLY if it is to be revised from that which was in the approved Plan) Copy of the enrollment projection in the approved LRFP. The historic enrollments used in the projections should include the latest FallEnrollment Report. a. New Construction Component (estimated): New Building GSF: Replacement GSF: Addition GSF: Demolition GSF: Acquisition of Existing Facility GSF: Required Information: Lot/Block & Descr. of Facility: Number of Students: Grades to be Housed: Name of the Programmatic Model (if applies): Educational Specifications/other Documents (only if available) b. Rehabilitation Constr'n Component(s) (estimated): Renovation and/or Alteration Capital Maintenance/Building System List Systems: Renovation of Facility as part of Acquisition Renovation and/or Alteration Required Information: Lot/Block & Descr. of Facility: Number of Students: Grades to be Housed: Name of the Programmatic Model (if applies): Educational Specifications/other Documents (only if available) I. Engagement of design consultants or other consultants to perform a feasibility study prior to application for approval of the above referenced School Facilities Project. Type of Feasibility Studies: V. Engagement of design consultants or other consultants in connection with site development and/or site remediation. I. Scope of Site Development: II. Scope of Site Remediation: V. For SDA Districts Only: Engagement of design consultants or other consultants in connection with acquisition of Temporary Classroom Units or other temporary facilities and any related design work and construction (these are in addition to requirements of (II) above): Type(s) of temporary space (estimated): Temp. Classroom Unit (TCU) #: Temp. Leased Space GSF: Temp. Leased Facility GSF: Temp. use of substandard space GSF: Other: GSF: Required Information: Lot/Block & Descr. of Facility: Number of Students: Grades to be Housed: Name of the Programmatic Model (if applies): Educational Specifications/other Documents (only if available) Additional Comments to assist DOE and/or SDA in understanding this pre-development request: FOR DOE-110 - : Page 2 of 2 Version 2.4.8db(02.26.16) FORM DOE-120 V 2.4.8db(02.26.16) Parent STATE OF NEW JERSEY DEPARTMENT OF EDUCATION - CHIEF OF STAFF OFFICE OF SCHOOL FACILITIES Land Temporary Feasibility Emergent STATE PROJECT#: 4550-050-17-1000 4550-050-17-1200 PROJECT APPLICATION Project and District Information (Note: Pre-Development Services do not constitute a "project;" use only Forms 001, 100 A& 110 when requesting Pre-Dev't Services.) County: District Name: District Number: School Name: School Code: UNION ROSELLE PARK BORO 4550 Roselle Park High School 050 District Contact: Contact Title: District Telephone #: District Fax #: District E-Mail: Susan Guercio Business Administrator 908-245-2103 908-245-1226 sguercio@rpsd.org Project Title: Project Address: Municipality: Zip Code: Temporary Classroom Unit at Roselle Park H 185 West Webster Avenue Roselle Park, NJ 07204 A/E Firm: A/E Contact: A/E Phone #: A/E Fax #: A/E E-Mail: DiCara Rubino Architects Jake Sentschak 973-256-0202 973-256-0227 jsentschak@dicararubino.com Brief Description of Project: Provide new Temporary Classroom Unit and all associated equipment. 1. District Type(s): 2. Identification of Project(s) from District's LRFP: (Identified on "Welcome-001" worksheet) SDA District District with 100% district aid % District with 55% and over district aid %  Regular Operating School District Level II District Other: 3. Project Type:  School Facilities Project (N.J.A.C.6A:26-3.2)  Other Capital Project (N.J.A.C.6A:26-3.12) 5. Type of Facility: Educational School Facility Other Facilities (i.e., offices, garage, storage, etc.)  Project not consistent w/LRFP - Amendment Required 4. Status of District's LRFP: Draft Determination issued by DOE Final Determination issued by DOE LRFP in Progress or Amendable LRFP Incomplete or Deficient Date: Date: Date: Date: 6. Project Scope (Check all that apply. Identify ONE TIER classification for New and Rehabilitation Component per N.J.S.A. 18A:7G-5(m)): 6A. New Construction Component: 6B. Rehabilitation Construction Component(s) Building GSF New GSF New Building Replacement Renovation and/or Reno GSF: Exist GSF Addition Capital Maintenance/Building System Impacted GSF: List Systems: Addition compared to Existing: Demolition Alteration Alt GSF: Demo GSF: Acquisition of Existing Facility . . . . . . . . and . . . . . . . . . . . . Facility GSF: 6C. Temporary Space: I. Temporary Space needed for: Swing Space during rehabilitation Capacity in advance of permanent construction Early Childhood - in advance of permanent construction (ECPA District) Other: Renovation of Facility as part of building Acquisition Facility GSF: Reno GSF: II. Type(s) of Temporary Space requested: Temp. Classroom Unit (TCU) Temp. Leased Space (p/o facility) Temp. Leased Facility (whole facility) Temp. use of substandard existing space Other: #: GSF: GSF: GSF: GSF: 1,800 7. Additional Project Characteristics (From 'Welcome-001' tab, provide additional information if required): Land Acquisition (N.J.A.C.6A:26-3.13) Demonstration Project (N.J.A.C.6A:26-3.15) Emergent Project (N.J.A.C.6A:26-3.16) Other:  Temporary Facilities (N.J.A.C.6A:26-3.14) Other: 8a. Local Funding Sources (Check all that apply) : Capital Outlay Capital Reserve Lease Purchase (Only less than 5 years is allowed; Comply w/ all requirements of N.J.A.C. 6A:26-10) Long Term Debt Short Term Notes/Debt Unexpended Bond Proceeds (Division approval is required for State Funding eligibility) Other: 8b. State Funding Sources (Elect only ONE of the following) : SDA Grant (N.J.S.A.18A:7G-15) DOE Debt Service Aid (N.J.S.A.18A:7G-9) SDA Grant County Vocational Rehabilitation Fund (N.J.A.C.6A:26-11.2) Project to be constructed by SDA (N.J.S.A.18A:7G-5) No State Funding Other: Other: Other: Other: FORM DOE-120 - PROJECT APPLICATION: Page 1 of 2 Version 2.4.8db(02.26.16) FORM DOE-120 Project Application (continued..) 9a. General Information (applicable to all projects) : Grades Housed at School: Name of Approved Model: Proposed: Existing: 10. Referendum Information (if applicable) : January (4th Tuesday) March (2nd Tuesday) April (3rd Tuesday) 9b. General Information ( NEW construction only) : # unhoused students being housed Area Allowance*: by new construction: (GSF/student) Proposed - Year: September (Last Tuesday) December (2nd Tuesday) None Referendum Passed Enter Date: One or More Checklists AND THE TRANSMITTAL Must Accompany This Form when sending your submission package to the NJDOE. Please review all checklists to verify which are applicable. They Include: ● School Facilities Project Submission Checklist Use Form-121 to I.D. submission requirements for your type of project DOE Form - 121 ● Various Land Acquisition and Disposal and Facility Closing Checklists DOE Forms - 150, 151, 152 Use Forms-150, -151, and -152 to I.D. additional submission requirements for projects involving Land Acquisition/Disposal or Facility Closing(s) ● Temporary Facilities Submission Checklist DOE Form - 126 Use Form-126 to I.D. additional submission requirements for projects involving temporary facilities ● Pre-Development Services Request. This is ALWAYS required for all Districts required to use the Authority. If this is a Pre-Development Application (a "Request for Pre-Development Services") DO NOT USE THIS APPLICATION FORM: Instead, go to DOE Form-110, and utilize that in place of this form, because a request for pre-development services does not constitute a project application, but, rather, is a request for services prior to a project application. Project Application Notes SDA Districts (N.J.A.C.6A:26–3.9(d)) 1) Prior to project submission, a Pre-Development request must be filed, and activities must be undertaken by the SDA. One exception is Other Capital Projects approved by the Abbott District's DOE Budget Manager. Districts with 55% and over DAP. (but non-Abbott) required to use the SDA (N.J.A.C.6A:26–3.9(d)) 1) Costs of Pre Development activities shall be funded locally and, once costs have been allocated to the applicable school facilities project, and that project has been approved pursuant to N.J.A.C. 6A:26-3.3, the district shall receive a credit toward the local share shall be allocated to the applicable approved project and deemed of the approved project. 2) District must apply to the SDA to engage architectural/engineering services in order to develop a school facilities project. If approval is obtained, the cost of developing the application is eligible for a state share funding. Executive Order 215 of 1989 ("EO-215"): 1) Projects approved for Preliminary Eligible Costs by DOE on or before December 18, 2001 are exempt from the requirements of Executive Order 215 per Executive Order 137 of 2001 . 2) Projects initiated by the State, as well as school facilities projects in which the State is granting at least 20 percent financial assistance and which meet certain cost thresholds (as in 3 and 4 below) and which are not otherwise exempted (as in 5 below), are required to comply with EO-215, including the preparation and submission of eiher an environmental assessment or an environmental impact statement, as applicable. NOTE: The assessment or impact statement shall be prepared as early in the planning and design process as possible, but in all cases submission and review must be completed prior to site preparation and/or any construction activity for the project. In the case of a project to be funded by the State, review of the assessment/impact statement must be completed by the DOE prior to awarding any financial assistance for the commencement of site preparation and/or any construction activity. If the school facilities project is approved by NJDOE, the district must still submit to NJDOE the assessment/impact statement for their submission to NJDEP with sufficient time to review per EO-215, prior to site preparation or any construction activities or receipt of State funds for same. (Submit 7 copies to NJDOE: 1 for NJDOE records, 6 to be forwarded by NJDOE to NJDEP for review). 3) Projects are subject to a Level I Environmental Assessment requirement if total construction cost > $1 million 4) Projects are subject to a Level II Environmental Impact Statement requirement if both total construction cost > $5 million, and more than 5 acres of land is disturbed. 5) Exemptions include: (a) maintenance, or repair projects, (b) facilities or equipment replaced in kind at the same location, (c) Renovations or rehabilitation of existing buildings, (d) Expansion or additions of existing buildings provided that the expansion or addition does not increase the building's capacity by more than 25% (e) Projects subject to review pursuant to the provisions of the Coastal Area Facility Review Act (CAFRA) ro the Municipal Wastewater Treatment Financing Program, (f) Projects which will require a full environmental impact statement pursuant to National Environmental Policy Act (NEPA), (g) projects classified as categorical exclusions pursuant to regulations promulgated in accordance with NEPA; or (h) Projects involving loans or tax exempt financing to private sector applications by departments, agencies or authorities of the State. Additional Comments: FORM DOE-120 - PROJECT APPLICATION: Page 2 of 2 Version 2.4.8db(02.26.16) FORM DOE-121 V 2.4.8db(02.26.16) Parent STATE OF NEW JERSEY DEPARTMENT OF EDUCATION - CHIEF OF STAFF OFFICE OF SCHOOL FACILITIES STATE PROJECT#: 4550-050-17-1000 Land Temporary Feasibility Emergent 4550-050-17-1200 SCHOOL FACILITIES PROJECT SUBMISSION CHECKLIST (Other Checklists may also apply. Read this checklist and DOE Forms-001, 002 & 010.) Project and District Information County: District Name: District Number: School Name: School Code: UNION ROSELLE PARK BORO 4550 Roselle Park High School 050 District Contact: Contact Title: District Phone #: District Fax #: District E-Mail: Susan Guercio Business Administrator 908-245-2103 908-245-1226 sguercio@rpsd.org Project Title: Project Address: Municipality: Zip Code: Temporary Classroom Unit at Roselle Park Hig 185 West Webster Avenue Roselle Park, NJ 07204 A/E Firm: A/E Contact: A/E Phone #: A/E Fax #: A/E E-Mail: DiCara Rubino Architects Jake Sentschak 973-256-0202 973-256-0227 jsentschak@dicararubino.com Brief Description of Project: Provide new Temporary Classroom Unit and all associated equipment. All project submissions to be in Quadruplicate (4 sets), except for Project Application Forms, Checklists and Fee, which require only the original to be sent. However, if you are requesting Release to the Local Code Official, please submit one original and two copies of that form. PLEASE NOTE THAT ALL PLANS ARE TO BE FOLDED - NOT ROLLED - WHEN SENT TO THE NJDOE. IF THIS PROJECT HAS NO CONSTRUCTION COMPONENT, BUT INVOLVES ONLY LAND ACQUISITION, LAND DISPOSAL OR CLOSING OF A SCHOOL FACILITY, DO NOT USE THIS FORM, BUT INSTEAD UTILIZE FORMS 150, 151 AND / OR 152 LARGE CHECK-BOXES INDICATE REQUIRED ATTACHMENTS, BUT ARE FOR DOE USE ONLY. I. INITIAL (Ed-Spec & Schematic) PROJECT SUBMISSION REQUIREMENTS for ALL Projects: ● Completed Form DOE-001 (Welcome Form) ● Completed Form DOE-100A (Transmittal - Non-SDA Projects), OR, Completed Form DOE-100B (Transmittal - SDA-Managed Projects) For delegated projects under 13A grant, submit copy of the notification of grant execution issued by SDA. ● Completed Form DOE-120 (Project Application) ● Completed Form DOE-121 (This Checklist Form) IN THE CASE OF PRIVATE SCHOOL FOR THE DISABLED: "Chief School Administrator" shall be the Executive Director & BOE shall be the Board of Trustees, & All Projects shall be "Other Capital" and include all requirements for an "Other Capital" Project - except these items are not required: Form 140, Cohort-Survival Enrollment, Room Inventory, Feasibility Study, & LRFP Project Detail Reports. ● Completed Form DOE-122 (Project Schedule) ● Completed Form DOE-130 (Project Cost Estimate Summary Form); This must be signed by the both BA and A/E. ● IF Rehabilitation Involved: Completed Form DOE-131 (Rehabilitation Costs Form) in addition to Form DOE-130 signed and sealed, approving the amendment to the previously approved LRFP. ● A Resolution of the district board of education approving the submission of the project to DOE, including any Temporary Spaces, if applicable. IF Other Capital Project, Resolution must state that the Project is "Other Capital" & BOE is not seeking state funding and amendment to the LRFP if applicable; (Board Resolution must be both signed and sealed) ● A copy of dated transmittal letter indicating submission of project documents to the county superintendent (superintendent of the county in which school is located) Copy of "LRFP" Project Detail Report indicating inclusion of full project scope in the Approved Plan. ● OR Copy of the amended "Abbott FMP" or "LRFP" Project Detail Report indicating the inclusion of full project scope in the proposed Amended Plan WITH DOE Form-140 completed (LRFP Amendment Request-see Form 140 above). ● A copy of the transmittal letter indicating the date of plan submission to the local planning board (s), whenever a TCU is to be constructed or the building footprint, volume, pedestrian or vehicular access, or amount of impervious area within the site are altered by the project (if applicable) ● If this is an Energy Service Project: Comply with all requirements of N.J.A.C. 6A:26 (Chapter 10) ● If this is an "Emergent Project: Letter from the County Superintendent with his/her declaring the project "Emergent" Ia. For Projects That DO NOT REQUIRE Educational Adequacy Review submit the following: (Non-Educational Temporary Space, Capital Maintenance, Renovation of non-educational Spaces, etc.): ● Optional: Completed Form DOE-124 (Authority Projects must be reviewed by DCA); Must be signed by both chief school administrator and municipal code enforcing agency chief ● A description of each of the functional components of the school facilities project (a detailed scope of work) signed by Chief School Administrator and Board President. Submit as an attachment (in lieu of Educational Specifications) ● Four sets of schematic plans. Drawing's Cover sheet must be signed by Chief School Administrator and Board President. ● NOTE: Projects that do not impact educational adequacy do not require a Final Plan Submission. FORM DOE-121 - SCHOOL FACILITIES PROJECT SUBMISSION CHECKLIST: Page 1 of 4 Version 2.4.8db(02.26.16) FORM DOE-121 V 2.4.8db(02.26.16) STATE OF NEW JERSEY DEPARTMENT OF EDUCATION - CHIEF OF STAFF OFFICE OF SCHOOL FACILITIES Parent Land Temporary Feasibility Emergent STATE PROJECT#: 4550-050-17-1000 4550-050-17-1200 SCHOOL FACILITIES PROJECT SUBMISSION CHECKLIST (Other Checklists may also apply. Read this checklist and DOE Forms-001, 002 & 010.) Project and District Information LARGE CHECK-BOXES INDICATE REQUIRED ATTACHMENTS, BUT ARE FOR DOE USE ONLY. Ib. For Projects That DO REQUIRE Educational Adequacy Review submit the following: (Edu'l Temporary Space, New Construction, Additions, Land Acquisition, Acquisition of existing building, Renovation and/or Alteration of educational spaces, ADA, …..; for complete listing, see N.J.A.C. 6A:26-5.1): ● IF DESIGN INCLUDES EDU'L VARIANCE: Submit Form-125 w/ attachments; Must be signed by A/E and Chief School Administrator ● If the project includes new construction, If last approved Cohort is older than one year, an updated Cohort-Survival Enrollment Projections is required; Must be certified (signed) by the Demographer or Chief School Administrator. Email DOE-Version cohort spreadsheet to County Manager ● Four sets of Educational Specifications (include Temporary Edu'l Space if applicable); Cover Page signed by Chief School Administrator. ● Four sets of Schematic Plans (include Temporary Edu'l Space if applicable); Each Sheet signed and sealed by A/E; Cover Sheet signed by the Chief School Administrator & Board President ● Identification and description of any spaces that exceed the facilities efficiency standards for which the district is seeking approval as additional space pursuant to N.J.A.C. 6A:26-3.3; ● LRFP Amendment Request Form if applicable; This form must be accompanied by a board resolution, ● Form DOE-160; Submit to DOE with a dated transmittal indicating this form was sent to the Office of Bilingual Education and Equity Issues ● For all New Construction only: Provide a completed Functional Capacity Worksheet of existing spaces in current facilities; District MUST utilize DOE's latest version of the Functional Capacity Worksheet (web-link provided on DOE Form-002) and email to County Mana ● For all New Construction in Lieu of Rehabilitation only: A feasibility study; If applicable, submit an attachment that details the reasons why new construction is required and existing structure(s) cannot be rehabilitated Ic. MORE INITIAL PROJECT SUBMISSION REQ'TS, ONLY for Projects That include ACQUISITION OF LAND: ● Land Acquisition Application and Checklist (DOE Form-150) and all required supporting documents as outlined on Form-150 NOTE 1: If the project includes land previously approved by DOE but District did not acquire the land within a three year period following date of the DOE approval, then District must provide DOE Form-150 and all supporting documents NOTE 2: If the project includes new use of land previously acquired by the District, then must provide DOE Form-150 and all supporting documents Id. MORE INITIAL PROJECT SUBMISSION REQ'TS, ONLY for Projects That include DISPOSAL OF LAND: ● Land Disposal Application and Checklist (DOE Form-151) and all required supporting documents as outlined on Form-151 Ie. MORE INITIAL PROJECT SUBMISSION REQ'TS, ONLY for Projects That include CLOSING OF A SCHOOL FACILITY: ● School Facility Closing Applic'n and Checklist (DOE Form-152) and all required supporting documents as outlined on Form-152 NOTE: For the purposes of NJDOE review and approval, Closing of a School Facility will not require any Final Review If. MORE INITIAL PROJECT SUBMISSION REQ'TS, ONLY for Projects That include TEMPORARY FACILITIES: ● Temporary Facilities Checklist (DOE-126) and all required supporting documents as outlined on Form-126 Ig. Deleted MORE INITIAL PROJECT SUBMISSION REQ'TS, ONLY for Projects that district intends to designate as a DEMONSTRATION PROJ ● Resolutions adopted by the BOE and the governing body of the municipality. ● Detailed, written proposed plan for carrying out the redevelopment project. ● Legal Name of the proposed redevelopment entity. ● Detailed, written description of how the project fits into the redevelopment plan. ● Detailed, written description of each of the community design features that are integrated into the project. Ih. MORE INITIAL PROJECT SUBMISSION REQ'TS, ONLY for Projects that involve ENTIRELY NEW SCHOOLS: ● Domestic Security and Preparedness Guidelines shall be followed per the Domestic Security Preparedness Act Best Practices NOTE 1: For New Schools Only NOTE 2: It is the Districts' Design Consultant's responsibility to coordinate the Domestic Security Preparedness design guidelines with all applicable codes including, but not limited to, NJ UCC and N.J.A.C. 6A:26. IN the event that a confilict between Domestic Securty Preparedness design guidelines and applicable code arise, the applicable code will prevail. Domestic Security Preparedness certification may be required for the construction. ● Certification by the Architect or Engineer that it is both the District and the A/E's intent to comply with the Best Practices (Click on this DCA logo to download guidelines) FORM DOE-121 - SCHOOL FACILITIES PROJECT SUBMISSION CHECKLIST: Page 2 of 4 Version 2.4.8db(02.26.16) FORM DOE-121 V 2.4.8db(02.26.16) STATE OF NEW JERSEY DEPARTMENT OF EDUCATION - CHIEF OF STAFF OFFICE OF SCHOOL FACILITIES Parent Land Temporary Feasibility Emergent STATE PROJECT#: 4550-050-17-1000 4550-050-17-1200 SCHOOL FACILITIES PROJECT SUBMISSION CHECKLIST (Other Checklists may also apply. Read this checklist and DOE Forms-001, 002 & 010.) Project and District Information ● LEED Guidelines shall be followed per Executive Order 24 NOTE 1: For New Schools Only; Additions are not covered under E. O. 24 NOTE 2: All new schools must achieve a minimum of 26 (Twenty Six) LEED design Points. NOTE 3: It is the District's Design Consultant's responsibility to coordinate the LEED design guidelines with all applicable codes including, but not limited to, NJ UCC and N.J.A.C. 6A:26. In the event that a conflict between LEED design guidelines and applicable codes arise, the applicable code will prevail. LEEDS Certification may be required for the construction. ● Certification by the Architect or Engineer that it is both the District and the A/E's intent to meet the minimum requirements of Executive Order 24. Note that at Final Educational Adequacy Submission, Evidence of LEED Credits will be required. (Click on this LEED logo to download checklist) LARGE CHECK-BOXES INDICATE REQUIRED ATTACHMENTS, BUT ARE FOR DOE USE ONLY. II. FINAL PROJECT SUBMISSION REQUIREMENTS: (Applies only to Projects Requiring Educational Adequacy Review) ● Completed Form DOE-001 (Welcome Form) ● Completed Form DOE-100A (Transmittal - Non-SDA Projects), OR, Completed Form DOE-100B (Transmittal - SDA-Managed Projects) ● Completed Form DOE-120 (Project Application) ● Completed Form DOE-121 (This Checklist Form) IN THE CASE OF PRIVATE SCHOOL FOR THE Disabled: "Chief School Administrator" shall be the Executive Director & BOE shall be the Board of Trustees, & All Projects shall be "Other Capital" and include all requirements for an "Other Capital" Project - except these items are not required: Form 140, Cohort-Survival Enrollment, Room Inventory, Feasibility Study, & LRFP Project Detail Reports. ● Completed Form DOE-122 (Project Schedule) ● Completed Form DOE-123 (Final Educ'l Review Fee Schedule) Fee dependent on the construction costs at time FEC set (See Form-123) ● Optional: Completed Form DOE-124 (Authority Projects must be reviewed by DCA); Must be signed by both chief school administrator and municipal code enforcing agency chief ● IF DESIGN INCLUDES EDU'L VARIANCE not approved at initial ap: Submit Form-125 w/ attach'ts; Must be signed by A/E & CSA ● IF DESIGN INCLUDES TEMPORARY SPACE: Also submit Form-126 w/ attach'ts ● Completed Form DOE-130 (Project Cost Estimate Summary Form); This must be signed by the both BA and A/E. ● IF Rehabilitation Involved: Completed Form DOE-131 (Rehabilitation Costs Form) in addition to Form DOE-130 ● Four sets of detailed plans; Each Plan signed and sealed by A/E; Cover Page signed by the Chief School Administrator & Board President NOTE: The submission for final educational adequacy review shall be construction documents that include the following (only documents related to site information or educational specifications need be submitted): • Architectural floor plans • Architecture/Engineering Site plan(s) showing R.O.W.s & limits of property, existing & proposed structures, environmentally sensitive areas, easements, deed restrictions and protective covenants and all proposed work outside the building envelope, including but not limited to: Drainage systems and basins, sanitary and potable water systems, drives and parking areas, pedestrian & ADA access, athletic fields, etc. • Architecture drawing (s) which allow verification of ceiling height and all other educational requirements of N.J.A.C. 6A:26-1.1 et seq. ● Copies of approval letters from ALL other State and/or Federal agencies having jurisdiction over the project In addition to copies of the approval letters, submit a statement signed by both the A/E and the Chief School Administrator indicating that all other state & federal approvals have been obtained (or are obtainable and WILL BE OBTAINED) prior to any construction activities at site(s). ● A check, payable to the “Treasurer, State of New Jersey;” Use Form DOE-123 to calculate amount III. CLOSE OUT PROJECT SUBMISSION REQUIREMENTS: IIIa. For projects having GRANTS as a state funding source, submit: ● A copy of the Grant close out phase. OR IIIb. For NON-GRANT projects (Other Capital Projects or projects having Debt Service Aid as a state funding Source), submit ALL OF the following: FORM DOE-121 - SCHOOL FACILITIES PROJECT SUBMISSION CHECKLIST: Page 3 of 4 Version 2.4.8db(02.26.16) FORM DOE-121 V 2.4.8db(02.26.16) STATE OF NEW JERSEY DEPARTMENT OF EDUCATION - CHIEF OF STAFF OFFICE OF SCHOOL FACILITIES Parent Land Temporary Feasibility Emergent SCHOOL FACILITIES PROJECT SUBMISSION CHECKLIST (Other Checklists may also apply. Read this checklist and DOE Forms-001, 002 & 010.) Project and District Information ● Transmittal Form 100A ● Project Application Form 120 ● Final Payment Voucher Form 170 ● Contract Procurement Compliance Certificate Form 171 ● List of Executed Contracts Form 172 ● Construction Plan Compliance Certification Form 173 ● Maintenance Plan. N.J.A.C. 6A:26-12.1 & N.J.A.C. 6:24-3.1 ● LRFP amendment request, if applicable IV. CHANGE ORDER SUBMISSION REQUIREMENTS: IVa. For Districts Required to use the Authoriity, submit the following AND any other docments required to document the need for a change during construction: ● Transmittal Form 100B ● Change Order Request Form-174 with all attachments IVa. For Districts NOT Required to use the Authoriity, submit the following AND any other docments required to document the need for a change during construction: ● Transmittal Form 100A ● Change Order Request Form-174 with all attachments FORM DOE-121 - SCHOOL FACILITIES PROJECT SUBMISSION CHECKLIST: Page 4 of 4 Version 2.4.8db(02.26.16) STATE PROJECT#: 4550-050-17-1000 4550-050-17-1200 FORM DOE-122 V 2.4.8db(02.26.16) Parent STATE OF NEW JERSEY DEPARTMENT OF EDUCATION - CHIEF OF STAFF OFFICE OF SCHOOL FACILITIES Land Temporary Feasibility Emergent STATE PROJECT#: 4550-050-17-1000 4550-050-17-1200 PROJECT SCHEDULE FORM Project and District Information County: District Name: District Number: School Name: School Code: UNION ROSELLE PARK BORO 4550 Roselle Park High School 050 District Contact: Contact Title: District Telephone #: District Fax #: District E-Mail: Susan Guercio Business Administrator 908-245-2103 908-245-1226 sguercio@rpsd.org Project Title: Project Address: Municipality: Zip Code: Temporary Classroom Unit at Roselle Park H 185 West Webster Avenue Roselle Park, NJ 07204 A/E Firm: A/E Contact: A/E Phone #: A/E Fax #: A/E E-Mail: DiCara Rubino Architects Jake Sentschak 973-256-0202 973-256-0227 jsentschak@dicararubino.com Brief Description of Project: Provide new Temporary Classroom Unit and all associated equipment. NOTE: This Project Schedule Form is required to be submitted for all projects except those undertaken by the AUTHORITY (SDA). For Authority Projects submit this schedule or other schedule containing the same milestones developed by the Authority. 1. Characteristics/Requirements of Project: Does Project Require Planning Board Submission: Yes No Does Project Require LRFP Amendment:  Yes No Does Project Require Final Education Review  Yes No No Referendum Required Specify on Line 9, Form 120 if req. Not Applicable 2. Project Schedule (Shaded cells require entry): Line Project Milestone Desired Start Date Duration (Days) Start Date End Date 5 01/26/17 01/31/17 Develop Ed. Specs., and Schematics 02/01/17 02/01/17 3 Submission of a complete project application to DOE 02/02/17 02/02/17 4 LRFP Amendment and issuance of Revised FDL by DOE 02/03/17 03/05/17 5 Submission to Planning Board (min 45 / 55 days)* 6 DOE determining a complete application 7 DOE Review and Approval/PEC Issuance 8 District review/response period for PEC (from 7 to 30 days) 1 Project Initiation (Request for State Project #) 2 01/26/17 30 1 jurisdiction): Municipal Code Enforcing Agency Construction Official (Name) : Municipal Code Enforcing Agency Construction Official (Signature) : Date: Municipal Code Enforcing Agency Classification is class: Municipal Code Enforcing Agency Address: Street: Phone: City: State: Zip Code: Fax: Comments/Notes for ease of UCC Review: FOR DCA* USE ONLY *Note: For all capital projects for NJ Private Schools for the Disabled, DOE will Approve this Form in place of DCA. Request Reviewed By: Title: Action: APPROVED Signature: Date Acted Upon: DENIED (identify reason below) RETURNED NO ACTION (identify reason below) Comments: FORM: DOE-124 - REQUEST FOR LOCAL RELEASE OF SCHOOL CONSTRUCTION PLANS: Page 1 of 1 Version 2.4.8db(02.26.16) FORM DOE-125 V 2.4.8db(02.26.16) Parent STATE OF NEW JERSEY DEPARTMENT OF EDUCATION - CHIEF OF STAFF OFFICE OF SCHOOL FACILITIES Land Temporary Feasibility Emergent STATE PROJECT#: 4550-050-17-1000 4550-050-17-1200 EDUCATIONAL VARIANCE APPLICATION AND CHECKLIST No Fee Associated with this Request Project and District Information [Use in addition to Project Application Form 120 and any applicable Project Checklists Series - DOE Form #121(a), (b)…, #150, etc.] County: District Name: District Number: School Name: School Code: UNION ROSELLE PARK BORO 4550 Roselle Park High School 050 District Contact: Contact Title: District Telephone #: District Fax #: District E-Mail: Susan Guercio Business Administrator 908-245-2103 908-245-1226 sguercio@rpsd.org Project Title: Project Address: Municipality: Zip Code: Temporary Classroom Unit at Roselle Park H 185 West Webster Avenue Roselle Park, NJ 07204 A/E Firm: A/E Contact: A/E Phone #: A/E Fax #: A/E E-Mail: DiCara Rubino Architects Jake Sentschak 973-256-0202 973-256-0227 jsentschak@dicararubino.com Brief Description of Project: Provide new Temporary Classroom Unit and all associated equipment. LARGE CHECK-BOXES INDICATE REQUIRED ATTACHMENTS BUT ARE FOR DOE USE ONLY. IN addition to a signed copy of THIS form, provide all of the following: 1. Describe variation request: Cite the FES, Educational Facility Standard, or Regulatory requirement from which variation is sought: 2. Describe impact of standards or requirements: Describe the difficulties that will result from compliance with the Department standards: 3. Describe alternative approach: Describe an alternative to the Department standard(s) that will protect the health, safety and welfare of students and assure educational adequacy: 4. Additional Comments or Descriptions: ● NOTE: Attach supporting information to facilitate evaluation of the request including plans, specifications, photographs, evaluations by County office, certifications, etc. as evidence for - and in support of - this variance request. Chief School Administrator: Date: Name: Pedro Garrido Signature: Architect/Engineer: Date: Name: Jake Sentschak Signature: FOR DOE USE ONLY Request Reviewed By: Title: Action: Signature: Date Acted Upon: APPROVED DENIED (identify reason below) RETURNED NO ACTION (identify reason below) Comments: FORM DOE-125 - EDUCATIONAL VARIANCE APPLICATION AND CHECKLIST: Page 1 of 1 Version 2.4.8db(02.26.16) FORM DOE-126 V 2.4.8db(02.26.16) STATE OF NEW JERSEY DEPARTMENT OF EDUCATION - CHIEF OF STAFF OFFICE OF SCHOOL FACILITIES Parent Land Temporary Feasibility Emergent STATE PROJECT#: 4550-050-17-1000 4550-050-17-1200 TEMPORARY FACILITIES APPLICATION AND CHECKLIST [Use in addition to Project Application Form 120 and any applicable Project Checklists Series - DOE Form #121(a), (b)…, #150, etc.] Project and District Information County: District Name: District Number: School Name: School Code: UNION ROSELLE PARK BORO 4550 Roselle Park High School 050 District Contact: Contact Title: District Telephone #: District Fax #: District E-Mail: Susan Guercio Business Administrator 908-245-2103 908-245-1226 sguercio@rpsd.org Project Title: Project Address: Municipality: Zip Code: Temporary Classroom Unit at Roselle Park H 185 West Webster Avenue Roselle Park, NJ 07204 A/E Firm: A/E Contact: A/E Phone #: A/E Fax #: A/E E-Mail: DiCara Rubino Architects Jake Sentschak 973-256-0202 973-256-0227 jsentschak@dicararubino.com Brief Description of Project: Provide new Temporary Classroom Unit and all associated equipment. LARGE CHECK-BOXES INDICATE REQUIRED ATTACHMENTS BUT ARE FOR DOE USE ONLY. THIS CHECKLIST IS IN ADDITION TO THE REQUIREMENTS OF FORM-121 I. FOR BOTH INITIAL AND FINAL PROJECT APPLICATIONS, PROVIDE ALL OF THE FOLLOWING: ● Describe the Type of Project associated with this Request: New Building/Addition-in advance of permanent construction Building Replacement Rehabilitation/Alteration/Capital Maintenance Acquisition/Renovation of Existing Facility Early Childhood-in advance of permanent construction Other: ● Intended use of Temporary Spaces:  For Educational Use 1b. Describe type(s) of Temp'y Space requested: Temporary Classroom Unit (TCU) # of TCU: Temporary Leased Space GSF: Temporary Leased Facility GSF: Temporary use of substandard existing space GSF: Other: GSF: For Non-Educational Use IN THE CASE OF A PRIVATE SCHOOL FOR THE DISABLED: "Chief School Administrator" shall be the Executive Director, BOE shall be the Board of Trustees, and all projects shall be "Other Capital" and include all requirements for an "Other Capital" Project. II. FOR INITIAL PROJECT APPLICATIONS ONLY, PROVIDE ALL OF THE FOLLOWING: IIa. If Temporary Facilities are for a Non-Educational Use: ● Provide statement detailing the condition that requires the use of temporary space; certify if space exists in a District facility for the required purpose, and, if so, if that space requires rehabilitation or if it is forthcoming. Submit as an attachment signed by Chief School Administrator (in lieu of Educational Specifications for the Temporary Space only) ● Provide Copy of District's Implementation Plan to County Superintendent indicating implementation plan/schedule for elimination of Temporary Space and provision of permanent facilities within 2 yrs. ● Provide Copy of letter from County Superintendent approving district's Implementation Plan. IIb. If Temporary Facilities are for an Educational Use: ● Provide statement detailing the condition that requires the use of temporary space; certify if space exists in a District facility for the required purpose, and, if so, if that space requires rehabilitation or if it is forthcoming. Submit as an attachment signed by BOTH the Chief School Administrator and the Board President. ● Provide Copy of District's Implementation Plan to County Superintendent indicating implementation plan/schedule for elimination of Temporary Space and provision of permanent facilities within 2 yrs. ● Provide Copy of letter from County Superintendent approving district's Implementation Plan. II. FOR FINAL PROJECT APPLICATIONS ONLY, PROVIDE ALL OF THE FOLLOWING: ● Just the items as required per Checklist Form-121. FORM DOE-126 - TEMPORARY FACILITIES APPLICATION AND CHECKLIST: Page 1 of 1 Version 2.4.8db(02.26.16) STATE PROJECT# : 4550-050-17-1000 FORM DOE-130 SUMMARY COST ESTIMATE FORM NJDOE - Chief of Staff - Office of School Facilities UNION ROSELLE PARK BORO 4550 Roselle Park High School 050 Temporary Classroom Unit at Roselle Park H 185 West Webster Avenue Roselle Park, NJ 07204 Parent Land Temporary Feasibility Emergent 4550-050-17-1200 Date: District Contact: Contact Title: District Telephone #: District Fax #: District E-Mail: Susan Guercio Business Administrator 908-245-2103 908-245-1226 sguercio@rpsd.org New Construction Hit if all costs are eligible BA (Signature/Name) Name: 2 3 3 3 4 5 6 7 8 9 # # # # # # # # # # # # # # # # # # # # # Building Construction Cost by Building System: Section: GENERAL CONDITIONS (% of all trades) 1-A Section: SITE IMPROVEMENTS 1-B Section: DEMOLITIONS 1-C Section: HAZARDOUS MATERIALS ABATEMENT 2 Section: FOUNDATIONS 3 Section: SUPERSTRUCTURE 4 Section: EXTERIOR CLOSURE 5 Section: INTERIOR CONSTRUCTION 6 Section: VERTICAL MOVEMENT 7 Section: PLUMBING 8 Section: HVAC 9 Section: SPRINKLER SYSTEM 10 Section: ELECTRICAL DISTRIBUTION 11 Section: COMMUNICATIONS 12 Section: FIXED FURNISHINGS 13 Section: ADA 14 Section: MISCELLANEOUS 15 Section: ALTERATIONS 16 Section: TEMPORARY FACILITIES 17 FF&E > 10 years of useful life Section: Total Building Construction Cost (Line 2-19) Other Allowable Costs: Section: 18 DOE Final Review Fee* 18 Section: Architectural/Engineering Design Fees 18 Section: Design Contingency-New (%) 18 Section: Design Contingency-Rehab (%) 18 Section: Bonding/Legal Fees 18 Section: Construction Management Fees/PMF 18 Section: Construction Administration Fees 18 Section: Testing Consultant Fees 18 Section: Environmental Consultant Fees 18 Section: Permits Fees Eligible Cost Estimated Cost Name: 1 Section: A.1 BUILDING ACQUISITION 1 Section: A.2 LAND ACQUISITION 1 Costs of Land & Building Acquisition Hit if all costs are ineligible Ineligible Cost $ $ $ - $ $ $ - $ $ $ - $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ - $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ - $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ - $ $ $ - $ $ $ - $ $ $ - $ $ $ - $ $ $ - $ $ $ - $ $ $ $ $ $ - $ $ $ $ $ $ - $ $ $ $ $ $ - # Section: # Section: 18 18 Const. Contingency-New (%) Min 5% Const. Contingency-Rehab (%) Min 5% $ - $ - $ - # Section: 18 Other (describe each): $ $ $ $ $ $ $ - $ $ $ $ $ $ $ - $ $ $ $ $ $ $ - $ - # UCC Review Fee # (sum = line 32) # # # # Total Other Allowable Costs (Line 21-37) # Other Allowable Costs as a % of Total Building Construction Cost Other Allowable Costs as a % of Total Building Construction Cost exceed 30%. A justification is required as part of this submission. 19 # Section: FF&E < 10 years of useful life # Total Project Costs *NOTE: The correct "DOE Final Review Fee" is to be based on "Total Building Construction Cost" figure (Line 20) at time the F.E.C. is approved by DOE. Version 2.4.8db(02.26.16) $ - $ - $ - $ - FORM DOE-130 SUMMARY COST ESTIMATE FORM NJDOE - Chief of Staff - Office of School Facilities Land Roselle Park, NJ 07204 4550-050-17-1200 Temporary Feasibility Emergent UNION ROSELLE PARK BORO 4550 Roselle Park High School 050 Temporary Classroom Unit at Roselle Park H 185 West Webster Avenue STATE PROJECT# : 4550-050-17-1000 Parent A/E Firm: A/E Contact: A/E Phone #: A/E Fax #: A/E E-Mail: DiCara Rubino Architects Jake Sentschak 973-256-0202 973-256-0227 jsentschak@dicararubino.com BA (Signature/Name) Rehabilitation Name: 2 3 3 3 4 5 6 7 8 9 # # # # # # # # # # # # # # # # # # # # # Building Construction Cost by Building System: Section: GENERAL CONDITIONS (% of all trades) 1-A Section: SITE IMPROVEMENTS 1-B Section: DEMOLITIONS 1-C Section: HAZARDOUS MATERIALS ABATEMENT 2 Section: FOUNDATIONS 3 Section: SUPERSTRUCTURE 4 Section: EXTERIOR CLOSURE 5 Section: INTERIOR CONSTRUCTION 6 Section: VERTICAL MOVEMENT 7 Section: PLUMBING 8 Section: HVAC 9 Section: SPRINKLER SYSTEM 10 Section: ELECTRICAL DISTRIBUTION 11 Section: COMMUNICATIONS 12 Section: FIXED FURNISHINGS 13 Section: ADA 14 Section: MISCELLANEOUS 15 Section: ALTERATIONS 16 Section: TEMPORARY FACILITIES 17 FF&E > 10 years of useful life Section: Total Building Construction Cost (Line 2-19) Other Allowable Costs: Section: 18 DOE Final Review Fee* 18 Section: Architectural/Engineering Design Fees 18 Section: Design Contingency-New (%) 18 Section: Design Contingency-Rehab (%) 18 Section: Bonding/Legal Fees 18 Section: Construction Management Fees/PMF 18 Section: Construction Administration Fees 18 Section: Testing Consultant Fees 18 Section: Environmental Consultant Fees 18 Section: Permits Fees # Section: # Section: 18 18 Const. Contingency-New (%) Min 5% Const. Contingency-Rehab (%) Min 5% # Section: 18 Other (describe each): UCC Review Fee # # (sum = line 32) # # # # Total Other Allowable Costs (Line 21-37) # Other Allowable Costs as a % of Total Building Construction Cost Other Allowable Costs as a % of Total Building Construction Cost exceed 30%. A justification is required as part of this submission. 19 # Section: FF&E < 10 years of useful life # Total Project Costs *NOTE: The correct "DOE Final Review Fee" is to be based on "Total Building Construction Cost" figure (Line 20) at time the F.E.C. is approved by DOE. Version 2.4.8db(02.26.16) Hit if all costs are ineligible Eligible Cost Ineligible Cost Estimated Cost Name: 1 Section: A.1 BUILDING ACQUISITION 1 Section: A.2 LAND ACQUISITION 1 Costs of Land & Building Acquisition Hit if all costs are eligible $ - $ - $ - $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ - $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ - $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ - $ - $ $ - $ $ - $ $ $ $ $ $ $ - $ $ $ $ $ $ $ - $ $ $ $ $ $ $ - $ - $ - $ - $ $ $ $ $ $ $ - $ $ $ $ $ $ $ - $ $ $ $ $ $ $ - $ - $ - $ - $ - $ - FORM DOE-130 SUMMARY COST ESTIMATE FORM NJDOE - Chief of Staff - Office of School Facilities STATE PROJECT# : 4550-050-17-1000 Parent Land 4550-050-17-1200 Temporary Feasibility Emergent UNION ROSELLE PARK BORO 4550 Roselle Park High School 050 LRFP Project #: Temporary Classroom Unit at Roselle Park H 185 West Webster Avenue Brief Description of Project: Provide new Temporary Classroom Unit and all associated equipment. Roselle Park, NJ 07204 BA (Signature/Name) Total of New Construction and Rehabilitation Name: 2 3 3 3 4 5 6 7 8 9 # # # # # # # # # # # # # # # # # # # # # Building Construction Cost by Building System: Section: GENERAL CONDITIONS (% of all trades) 1-A Section: SITE IMPROVEMENTS 1-B Section: DEMOLITIONS 1-C Section: HAZARDOUS MATERIALS ABATEMENT 2 Section: FOUNDATIONS 3 Section: SUPERSTRUCTURE 4 Section: EXTERIOR CLOSURE 5 Section: INTERIOR CONSTRUCTION 6 Section: VERTICAL MOVEMENT 7 Section: PLUMBING 8 Section: HVAC 9 Section: SPRINKLER SYSTEM 10 Section: ELECTRICAL DISTRIBUTION 11 Section: COMMUNICATIONS 12 Section: FIXED FURNISHINGS 13 Section: ADA 14 Section: MISCELLANEOUS 15 Section: ALTERATIONS 16 Section: TEMPORARY FACILITIES 17 FF&E > 10 years of useful life Section: Total Building Construction Cost (Line 2-19) Other Allowable Costs: Section: 18 DOE Final Review Fee* 18 Section: Architectural/Engineering Design Fees 18 Section: Design Contingency-New (%) 18 Section: Design Contingency-Rehab (%) 18 Section: Bonding/Legal Fees 18 Section: Construction Management Fees/PMF 18 Section: Construction Administration Fees 18 Section: Testing Consultant Fees 18 Section: Environmental Consultant Fees 18 Section: Permits Fees # Section: # Section: 18 18 Const. Contingency-New (%) Min 5% Const. Contingency-Rehab (%) Min 5% # Section: 18 Other (describe each): UCC Review Fee # # (sum = line 32) # # # # Total Other Allowable Costs (Line 21-37) # Other Allowable Costs as a % of Total Building Construction Cost Other Allowable Costs as a % of Total Building Construction Cost exceed 30%. A justification is required as part of this submission. 19 # Section: FF&E < 10 years of useful life # Total Project Costs *NOTE: The correct "DOE Final Review Fee" is to be based on "Total Building Construction Cost" figure (Line 20) at time the F.E.C. is approved by DOE. Version 2.4.8db(02.26.16) Estimated Cost Name: 1 Section: A.1 BUILDING ACQUISITION 1 Section: A.2 LAND ACQUISITION 1 Costs of Land & Building Acquisition Eligible Cost Ineligible Cost $ $ $ - $ $ $ - $ $ $ - $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ - $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ - $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ - $ $ - $ $ - $ $ - $ - $ - $ - $ $ $ $ $ $ - $ $ $ $ $ $ - $ $ $ $ $ $ - $ - $ - $ - $ $ $ $ $ $ $ - $ $ $ $ $ $ $ - $ $ $ $ $ $ $ - $ - $ - $ - $ - $ - FORM DOE-131 V 2.4.8db(02.26.16) STATE OF NEW JERSEY DEPARTMENT OF EDUCATION - CHIEF OF STAFF OFFICE OF SCHOOL FACILITIES T F DETAILED REHABILITATION COST ESTIMATE FORM UNION / 39 ROSELLE PARK BORO 4550 Roselle Park High School 050 County: District Name: District Number: School Name: School Code: Date Submitted: Temporary Classroom Unit at Roselle Park Hi Project Title: LRFP Project No's: NOTE: This form is provided in support of ( not in place of ) the detailed cost estimates that ARE REQUIRED in the case of rehabilitation projects. Costs entered on this sheet should include all r and only rehabilitation scope costs. These figures are transferred automatically to Form 130 - Project Cost Estimate, which is a summation of both New Construction and Rehabilitation Costs. System 1 System 2 3 Section Section/System 36 Site Improvements 37 Athletic Facilities 1-A Total Site Improvements: System 4 5 Section System 6 7 Section Scope Description Quantity Unit SF EA $ $ Unit Price - Demolitions 1-B Total Demolitions: SF $ - Hazardous Materials Abatement 1-C Total Hazardous Materials Abatement: SF $ - System 8 9 Section 1 2 Structural Foundations Total Foundations: LF $ - System # # Section 2 3 Superstructure Total Superstructure: GSF $ - System # System # # System # System # Section 3 4 5 6 4 Walls Windows and Glazed Walls Doors and Frames Roofs Total Exterior Closure: SF SF EA SF $ $ $ $ - System # # System # System # System # System # System # System # Section 7 8 9 10 11 12 13 5 Partitions Interior Doors Stair Construction Stair Finishes Wall Finishes Floor Finishes Ceiling Finishes Total Interior Construction: SF EA Flight LF SF SF SF $ $ $ $ $ $ $ - # System # Section 14 Elevators and Lifts 6 Total Vertical Movement: EA $ - # System # System # System # System # System # Section 15 16 17 18 19 7 GSF EA SF SF SF $ $ $ $ $ - Domestic Water Distribution Piping Hot Water Supply - Generation Plumbing Fixtures Sanitary Piping Storm Water Riser Piping Total Plumbing: FORM DOE-131 - DETAILED REHABILITATION COST ESTIMATE FORM: Page 1 of 2 Version 2.4.8db(02.26.16) FORM DOE-131 V 2.4.8db(02.26.16) STATE OF NEW JERSEY DEPARTMENT OF EDUCATION - CHIEF OF STAFF OFFICE OF SCHOOL FACILITIES T F DETAILED REHABILITATION COST ESTIMATE FORM Continued, Page 2 of 2 SF SF SF EA SF $ $ $ $ $ - SF SF $ $ - Unit EA EA SF EA EA EA Kw $ $ $ $ $ $ $ Unit Price - 33 Communication & Security Systems 34 Special Systems 11 Total Communications: SF SF $ $ - # System # Section 38 Fixed Furnishings 12 Total Fixed Furnishings: EA $ - # System # Section 39 ADA Upgrades 13 Total ADA: EA $ - # System # Section 40 Miscellaneous Building Code 14 Total Miscellaneous: EA $ - # System # Section Alteration 15 Total Alteration: SF # System # Section TCU's or other temporary facilities 16 Total Temporary Facilities: EA $ - # System # System # System # Section Furnishing Fixtures Equipment 17 Total Furnishing, Fixtures & Equipment with useful life of 10 years and greater (FF&E > 10 years): FF&E are eligible for funding if the project qualifies as "Reconstruction" as defined in the UCC EA EA EA $ $ $ - EA EA EA $ $ $ - # System # System # System # System # System # Section 20 21 22 23 24 8 # System # System # Section 25 Fire Sprinkler System Types 26 Standpipe & Hose Systems 9 Total Sprinkler System: # System # System # System # System # System # System # System # Section 27 28 29 30 31 32 35 10 # System # System # Section # # Section Heating System Types Cooling System Types Heating/Cooling Systems Exhaust Ventilation Types HVAC Controls Total HVAC: Section/System Scope Description Building Service Branch Panels Interior Lighting Exterior Lighting Exit Signs Power & Outlets Emergency Power Total Electrical Distribution System: Quantity 18 Total Other Allowable Costs (Fill this section for rehab projects on Form 130) # System # System # System # Section Furnishing Fixtures Equipment 19 Total Furnishing, Fixtures & Equipment with useful life less 10 years (FF&E < 10 years) Not an allowable Cost: Rehabilitation Summation: # Total Rehabilitation Costs: FORM DOE-131 - DETAILED REHABILITATION COST ESTIMATE FORM: Page 2 of 2 Version 2.4.8db(02.26.16) Parent Land Temporary Feasibility STATE PROJECT# : 4550-050-17-1000 4550-050-17-1200 Emergent igh School rehabilitation scope costs, Totals Version 2.4.8db(02.26.16) $ $ $ - $ $ - $ $ - $ $ - $ $ - $ $ $ $ $ - $ $ $ $ $ $ $ $ - $ $ - $ $ $ $ $ $ - Parent Land Temporary Feasibility STATE PROJECT# : 4550-050-17-1000 4550-050-17-1200 Emergent $ $ $ $ $ $ - $ $ $ Totals Version 2.4.8db(02.26.16) $ $ $ $ $ $ $ $ - $ $ $ - $ $ - $ $ - $ $ - $ $ - $ $ - $ $ $ $ - $ - $ $ $ $ - $ - FORM DOE-150 V 2.4.8db(02.26.16) Parent STATE OF NEW JERSEY DEPARTMENT OF EDUCATION - CHIEF OF STAFF OFFICE OF SCHOOL FACILITIES Land Temporary Feasibility Emergent STATE PROJECT#: 4550-050-17-1000 4550-050-17-1200 LAND ACQUISITION APPLICATION AND CHECKLIST [Use in addition to Project Application Form 120 and any applicable Project Checklists Series - DOE Form #121(a), (b)…] Project and District Information County: District Name: District Number: School Name: School Code: UNION ROSELLE PARK BORO 4550 Roselle Park High School 050 District Contact: Contact Title: District Telephone #: District Fax #: District E-Mail: Susan Guercio Business Administrator 908-245-2103 908-245-1226 sguercio@rpsd.org Project Title: Project Address: Municipality: Zip Code: Temporary Classroom Unit at Roselle Park H 185 West Webster Avenue Roselle Park, NJ 07204 A/E Firm: A/E Contact: A/E Phone #: A/E Fax #: A/E E-Mail: DiCara Rubino Architects Jake Sentschak 973-256-0202 973-256-0227 jsentschak@dicararubino.com IF RENOVATIONS OR NEW CONSTRUCTION OR TCU's OR SITE WORK ARE PART OF THIS APPLICATION, THIS CHECKLIST MUST BE ACCOMPANIED BY FORM-121 AND ALL ITS REQUIRED ATTACHMENTS IN THE CASE OF A PRIVATE SCHOOL FOR THE DISABLED: "Chief School Administrator" shall be the Executive Director, BOE shall be the Board of Trustees, & All Projects shall be "Other Capital" and include all requirements for an "Other Capital" Project - except these items are not required: Any School District Maps. LARGE CHECK-BOXES INDICATE REQUIRED ATTACHMENTS BUT ARE FOR DOE USE ONLY. I. IF there is no construction component to this project, provide the following: ● Completed Form DOE-001 ● Completed Form DOE-100A (Transmittal - Non-SDA Projects), OR, Completed Form DOE-100B (Transmittal - SDA-Managed Projects) ● Completed Form DOE-120 II. IF there is a construction component to this project, provide the following: This checklist is required to be submitted with any applications to the department for approval of Land Acquisition. It serves to ensure that all submittals and approvals required pursuant to N.J.A.C. 6A:26-7.1 and 7.2 are satisfied prior to Land Acquisition. ● Completed Form DOE-121 (use checklist 121 in addition to Form-150) III. IN EVERY CASE, provide the following: ● Written Request for Approval of Land Acquisition: a) A written request for approval from the district, which shall include a statement, signed by the board president and the chief school administrator, indicating the immediate and ultimate proposed uses of the site, in terms of building use, grade organization and potential maximum enrollment, and whether the land is, or will be, part of a school facilities project indicated in the district’s LRFP; b) Is the Land Acquisition now, or will it be, part of a school facilities project? ● Written Statement from governing local / county water and sewerage agency indicating the following: a) Land can be adequately provided with the necessary water for the proposed maximum enrollment and use b) Land can be adequately provided with an acceptable sewerage disposal system for the proposed maximum enrollment and use c) Whether the necessary water and/or sewerage infrastructure is, or is not, already in place to service the requirements of the site ● Statements from NJ Department of Environmental Protection or licensed RA/PE/PP (architect, engineer or professional planner): a) Whether the land is subject to regulation under Wetland, Pinelands, or the Waterfront Development Acts, the Greenacres Act, or other statues, regulations or Executive Orders administered by agencies of state or federal government. b) If so subject, adequate documentation to demonstrate such approvals can & will be obtained and not affect the adequacy or timliness of the site. c) Whether the land is in an area designated for growth under the NJ State Development and Redevelopment Plan; provide the name and description of the Plan Area. ● Written statement from licensed architect or licensed engineer, specifying suitability of land for intended purpose: a) Whether or not the land is suitable for the current and ultimate proposed school use(s) and if it will meet the requirements of N.J.A.C. 6A:26-7.1(c) and (d) ● Plot plan of land to be acquired (a title search and deed research are recommended to properly effect the following): a) A completed plot plan or survey of the land to be acquired showing: topographical and contour lines, all structures on property and their uses, all streams, easements, deed restrictions, protective covenants, all adjacent properties and access roads. The acreage and dimensions of the tract proposed for acquisition shall be included as per the application of the standards for minimum acceptable school site sizes in NJAC 6A:26-7.1(c), b) Such plot plan or survey shall indicate the proposed building, parking, other structures, setback and site improvements locations, including a 30' access around any proposed school building(s) ● School district map showing the subject property location and the location(s) of other existing schools. ● School district map showing proposed attendance area to be served and the number of students. ● Office of Bilingual Education & Equity Issues Racial/Ethnic Enrollment Questionnaire showing impact on racial balance a) Use form DOE-160 which covers the required information. Provide to DOE a copy of Form DOE-160 AND copy of transmittal showing when form was sent to OBE&EI ● If the land being acquired includes existing facilities: a) Indicate the intended use and/or disposition of all existing buildings. Any building to be acquired must conform with UCC req. and educational adequacy requirements of N.J.A.C. 6A:26-5.1 et seq. which apply to construction of facilities. ● Submission to local planning board(s) is required: Provide the recommendations of the local planning board of the municipality(s) in which the site is situated and which board has an approved master plan, as required by N.J.S.A. 40:55D-31, 18A:18A-49 and 18A:18A-16; FORM DOE-150 - LAND ACQUISITION APPLICATION AND CHECKLIST: Page 1 of 2 Version 2.4.8db(02.26.16) FORM DOE-150 V 2.4.8db(02.26.16) STATE OF NEW JERSEY DEPARTMENT OF EDUCATION - CHIEF OF STAFF OFFICE OF SCHOOL FACILITIES Parent STATE PROJECT#: 4550-050-17-1000 Land Temporary Feasibility Emergent 4550-050-17-1200 Land Acquisition Checklist (continued..) LARGE CHECK-BOXES INDICATE REQUIRED ATTACHMENTS BUT ARE FOR DOE USE ONLY. ● Prior approval of or review by other agencies: a) These may include (but are not limited to) NJDEP, Pinelands Act, Wetlands Delineation, US Corp. of Engineers, etc. ● Documentation that available data on soil conditions has been examined by licensed architect or engineer and was determined to be sufficient for the intended use. ● Reports by a licensed architect or engineer of actual soil test borings and groundwater tests on any site located less than one mile from landfill; alternately, environmental/structural assessment of subject property(s) in format acceptable to DOE ● Detailed appraisal of the property's market value prepared by licensed professional ● Recommendations of the County Superintendent of Schools based on requirements of N.J.A.C. 6A:26-7.1 Requirements/considerations per N.J.A.C. 6A:26-7.1 : 6A:26-7.1(c): School sizes shall be directly related to the acreage required for the structures and activities to be situated thereon. Acreage except where specifically notes, shall be considered for single use 6A:26-7.1(d): All school sites require sufficient acreage for; (1) the placement of the school facility, (2) expansion of the building to its maximum potential enrollment, (3) placement of other structures, (4) multi-purpose physical education and recreation fields required to support the Core Curriculum Content Standards as defined by the educational specifications, (5) disabled accessible pedestrian walkways, roadways, and parking areas, (6) public access and service roads onto the site including, where warranted, a one-way school bus road of 30 foot width, a two way road of 36 foot width, a school bus drop-off area, and a 18 foot wide posted fire lanes. (7) A 30 foot wide access around the entire building. 6A:26-7.1(e): Land owned by district board of education which does not meet the standards of this section may be supplemented by adjacent municipally-owned land if such land is formally leased on a long-term basis for exclusive use during school hours 6A:26-7.1(f): The approval of the Division shall remain effective for three years after which time Division approval shall again be obtained prior to acquiring land. DOE Land previously approved for different a project or use must comply with all requirements of this checklist. For the District's use, some Agency Approvals that may apply to this Land Acquisition include, but are not limited to: Some of NJ Department of Environmental Protection Programs: a) Land Use Regulation Program: i) Waterfront Development Act ii) Wetlands Act of 1970 iii) Coastal Area Facility Review Act (CAFRA) iv) Flood Hazard Area Control Act (Stream Encroachment) v) Riparian Lands Management Program (Tidelands conveyance) Contact: NJDEP Land Use Regulation, Application Support Unit P.O.Box 439, Trenton, NJ 08625-0439 (609) 777-0456 b) Historic Places Encroachment: Contact: NJDEP Division of Parks and Forestry Historic Preservation Office P.O.Box 404, Trenton, NJ 08625-0404 (609) 292-2023 c) Green Acres Program: Contact: NJDEP Green Acres Program Bureau of Legal Services and Compliance P.O.Box 412, Trenton, NJ 08625-0412 (609) 984-0631 Delaware and Raritan Canal Contact: Delaware and Raritan Canal Commission Prallsville Mills P.O.Box 539, Stockton NJ 08559-0539 (609) 397-2000 Hackensack Meadowlands Contact: Hackensack Meadowlands Development Comm. One DeKorte Park Plaza Lyndhurst, NJ 07071 (201) 460-1700 Pinelands Contact: New Jersey Pinelands Commission P.O. Box 7 (Springfield Road) New Lisbon, NJ 08604 (609) 894-9344 Regional Soil Conservation Service Office Contact: New Jersey Soil Conservation Committee John-Fitch Plaza, Room 204 P.O. Box 330 Trenton, NJ 08625 (609) 292-5540 State Agriculture Development Committee a) Agricultural Development Area Phone: (609) 984-2504 b) Farmland Preservation Program Contact: State Agricultural Development Committee Health/Agricultural Building – John Fitch Plaza P.O. Box 330 Trenton, NJ 08625-0330 (609) 984-2504 Delaware River Basin Commission Contact: Delaware River Basin Commission; P.O.Box 7360 (25 State Police Drive) West Trenton NJ 883-9499 [(609) 397-2000] * NJDEP ONE STOP PROCESS ONE STOP is a total facility approach; a coordinated permitting and compliance assistance process. A permittee can now turn to one source to identify all permits required for a development or significant facility start-up or expansion project and maintain consistent contact throughout the process. This process will allow the Department to provide better customer service to the public and regulated entities. Click on the NJDEP-ONE STOP Logo to learn more about this helpful guidance program! FORM DOE-150 - LAND ACQUISITION APPLICATION AND CHECKLIST: Page 2 of 2 Version 2.4.8db(02.26.16) FORM: DOE-151 V 2.4.8db(02.26.16) Parent STATE OF NEW JERSEY DEPARTMENT OF EDUCATION - CHIEF OF STAFF OFFICE OF SCHOOL FACILITIES Land Temporary Feasibility Emergent STATE PROJECT#: 4550-050-17-1000 4550-050-17-1200 DISPOSAL OF LAND APPLICATION AND CHECKLIST Project and District Information [Use in addition to Project Application Form 120 and any applicable Project Checklists Series - DOE Form #121(a), (b)…, #152, etc.] County: District Name: District Number: School Name: School Code: UNION ROSELLE PARK BORO 4550 Roselle Park High School 050 District Contact: Contact Title: District Telephone #: District Fax #: District E-Mail: Susan Guercio Business Administrator 908-245-2103 908-245-1226 sguercio@rpsd.org Project Title: Project Address: Municipality: Zip Code: Temporary Classroom Unit at Roselle Park H 185 West Webster Avenue Roselle Park, NJ 07204 A/E Firm: A/E Contact: A/E Phone #: A/E Fax #: A/E E-Mail: DiCara Rubino Architects Jake Sentschak 973-256-0202 973-256-0227 jsentschak@dicararubino.com Brief Description of Project: Provide new Temporary Classroom Unit and all associated equipment. IN THE CASE OF A PRIVATE SCHOOL FOR THE DISABLED: "Chief School Administrator" shall be the Executive Director, BOE shall be the Board of Trustees, & All Projects shall be "Other Capital" and include all requirements for an "Other Capital" Project - except these items are not required: Cohort-Survival Enrollment and LRFP Reports. LARGE CHECK-BOXES INDICATE REQUIRED ATTACHMENTS BUT ARE FOR DOE USE ONLY. I. IF there is no construction component to this project, provide the following: ● Completed Form DOE-001 ● Completed Form DOE-100 ● Completed Form DOE-120 II. IF there is a construction component to this project, provide the following: ● Completed Form DOE-121 (if project has construction component) This checklist is required to be submitted with any applications to the department for approval of Disposal of Land. It serves to ensure that all submittals and approvals required for a Land Disposal are satisfied. III. IN EVERY CASE, provide the following site information: ● Tax Map of all properties to be disposed of, with subject property denoted thereon ● Site Location Map (i.e., U.S.G.S. or Street Map) a. Identification of Project(s) from District's LRFP:  Project not in LRFP - Amendment requested LRFP Project Number(s) from LRFP annotated report: ● Copy of the LRFP Annotated Report b. Property Identification (Provide a Tax Map): Address: Lot # Block # oes the Site have Improvements? No Yes Disposal of entire site Disposal of partial site Total Acreage: Total Acreage: Size disposed (If yes, what type of Improvements/Facilities:) c. How is Property to be Disposed of: The property will be sold to private entity through public auction The property will be sold to a state agent under an exception to the public auction requirements of N.J.S.A.18A:20-10 Transfer/Exchange of entire site . . . OR . . . Transfer/Exchange of partial site (i.e., easement or subdivision) d. Site acquisition information: How did the District acquire the land? What funding source was used to acquire the land? When did the District acquired the land? Are there any deed restrictions, easements or protective covenants associated with the land or any structure on the land? No Yes If Yes, explain: e. Buyer information: Name: Contact Name: Contact #: Address: Proposed sale price: Fair market value: FORM: DOE-151 - DISPOSAL OF LAND APPLICATION AND CHECKLIST: Page 1 of 2 Version 2.4.8db(02.26.16) FORM: DOE-151 V 2.4.8db(02.26.16) STATE OF NEW JERSEY DEPARTMENT OF EDUCATION - CHIEF OF STAFF OFFICE OF SCHOOL FACILITIES Parent Land Temporary Feasibility Emergent STATE PROJECT#: 4550-050-17-1000 4550-050-17-1200 Disposal of Land Checklist (continued..) IV. IN EVERY CASE, provide the following evidence and authorizing documents: ● Copy of the request by the District to the County Superintendent. ● Copy of the County Superintendent’s recommendations to the NJDOE ● Signed and Sealed Board Resolution authorizing sale/disposal of property, and permitted method by which the disposal is to occur ● Necessary updates to the enrollment projections (if more than 1 year old) in the district's approved LRFP to support the project. ● Superintendent's signed statement indicating the impact that the disposal will have on educational adequacy of the individual site and of the District as a whole ● Where the disposal of land also includes closing of a school, also complete DOE Form-152 Comments/Notes: FORM: DOE-151 - DISPOSAL OF LAND APPLICATION AND CHECKLIST: Page 2 of 2 Version 2.4.8db(02.26.16) FORM: DOE-152 V 2.4.8db(02.26.16) Parent STATE OF NEW JERSEY DEPARTMENT OF EDUCATION - CHIEF OF STAFF OFFICE OF SCHOOL FACILITIES Land Temporary Feasibility Emergent STATE PROJECT#: 4550-050-17-1000 4550-050-17-1200 CLOSING OF SCHOOL FACILITY APPLICATION AND CHECKLIST Project and District Information [Use in addition to Project Application Form 120 and any applicable Project Checklists Series - DOE Form #121(a), (b)…, #151, etc.] County: District Name: District Number: School Name: School Code: UNION ROSELLE PARK BORO 4550 Roselle Park High School 050 District Contact: Contact Title: District Telephone #: District Fax #: District E-Mail: Susan Guercio Business Administrator 908-245-2103 908-245-1226 sguercio@rpsd.org Project Title: Project Address: Municipality: Zip Code: Temporary Classroom Unit at Roselle Park H 185 West Webster Avenue Roselle Park, NJ 07204 A/E Firm: A/E Contact: A/E Phone #: A/E Fax #: A/E E-Mail: DiCara Rubino Architects Jake Sentschak 973-256-0202 973-256-0227 jsentschak@dicararubino.com Brief Description of Project: Provide new Temporary Classroom Unit and all associated equipment. IN THE CASE OF A PRIVATE SCHOOL FOR THE DISABLED: "Chief School Administrator" shall be the Executive Director, BOE shall be the Board of Trustees, & All Projects shall be "Other Capital" and include all requirements for an "Other Capital" Project - except these items are not required: Cohort-Survivla Enrollment, Models, Functional Capacity Calculations and LRFP Reports. LARGE CHECK-BOXES INDICATE REQUIRED ATTACHMENTS BUT ARE FOR DOE USE ONLY. I. IF there is no construction component to this project, provide the following: ● Completed Form DOE-001 ● Completed Form DOE-100 ● Completed Form DOE-120 II. IF there is a construction component to this project, provide the following: ● Completed Form DOE-121 (if project has construction component) III. IN EVERY CASE, provide the following facility information: This checklist is required to be submitted with any applications to the department for approval of the Closing of a School Facility. It serves to ensure that all submittals and approvals required for a School Closing are satisfied. ● Site Location Map (i.e., U.S.G.S. or Street Map) a. Identification of Project(s) from District's LRFP:  Project not in LRFP - Amendment requested Project in LRFP ● Copy of the LRFP Annotated Report b. Building(s) capacity: The District shall demonstrate that sufficient school building capacity exists to house district students following such closing for the succeeding five years by submitting the following: ● Necessary updates to the enrollment projections in the district's approved LRFP to support the project. ● Copies of Proposed Room Inventory from the LRFP. ● Functional Capacity Worksheet for existing facilities in the district impacted by the closing of the school c. Substandard Spaces: ● In Written Form: Demonstrate that the use of substandard spaces in the remaining schools does not result or increase from an overall facilities shortage caused by the school closing. d. Student Reassignment: The re-assignment of students to other schools in the district must not produce, sustain nor contribute to unlawful segregation, separation or isolation of student populations on the basis of race or national origin. ● Office of Bilingual Education & Equity Issues Racial/Ethnic Enrollment Questionnaire showing impact on racial balance Use form DOE-160 which covers the required information. Provide to DOE a copy of Form DOE-160 AND copy of transmittal showing when form was sent to OBE&EI IV. IN EVERY CASE, provide the following evidence and authorizing documents: ● Copy of the request by the District to the County Superintendent ● Copy of the County Superintendent’s recommendations to the NJDOE ● Signed and sealed Board Resolution authorizing the closing of the school ● Where the closing of the school includes disposal of the land on which it lies, also complete Form-151 Comments/Notes: FORM: DOE-152 - CLOSING OF SCHOOL FACILITY APPLICATION AND CHECKLIST: Page 1 of 1 Version 2.4.8db(02.26.16) FORM: DOE-170 V 2.4.8db(02.26.16) STATE OF NEW JERSEY DEPARTMENT OF EDUCATION - CHIEF OF STAFF OFFICE OF SCHOOL FACILITIES STATE PROJECT#: 4550-050-17-1000 Parent Land Temporary Feasibility Emergent 4550-050-17-1200 PAYMENT VOUCHER FORM This Form is for ROD Grant Projects Only County: District Name: District Number: School Name: School Code: UNION ROSELLE PARK BORO 4550 Roselle Park High School 050 District Contact: Contact Title: District Telephone #: District Fax #: District E-Mail: Susan Guercio Business Administrator 908-245-2103 908-245-1226 sguercio@rpsd.org Project Title: Project Address: Municipality: Zip Code: Temporary Classroom Unit at Roselle Park H 185 West Webster Avenue Roselle Park, NJ 07204 A/E Firm: A/E Contact: A/E Phone #: A/E Fax #: A/E E-Mail: DiCara Rubino Architects Jake Sentschak 973-256-0202 973-256-0227 jsentschak@dicararubino.com Brief Description of Project: Provide new Temporary Classroom Unit and all associated equipment. Contract # Vendor Type of Service Awarded Amount Total Approved Change orders Contract Balance Total Payout to date on Contract NOTE: List Change Orders for each contract/contracted trade separately. Total payout to date is by contract/contracted trade. Use multiple forms if required. $ $ $ $ - Total $ - $ - $ - $ - - Certification by Contractor/Vendor: This Payment Voucher has been reviewed and found to be accurate and in accordance with the contract documents and all other applicable laws. I hereby certify that to the best of my knowledge, all work covered by this Payment Voucher has been completed in accordance with the contract documents. Contractor/Vendor Authorized person (Signature) : Date: Contractor/Vendor Authorized person (Type Name) : Certification by School Business Administrator: This Payment Voucher and vendor list has been reviewed and found to be accurate and in accordance with the requirements of N.J.A.C. 6A:26 and all other applicable laws. I hereby certify that to the best of my knowledge, all work covered by this Payment Voucher has been completed in accordance with the approved school facilities project. School Business Administrator (Signature) : School Business Administrator: Date: Susan Guercio FORM: DOE-170 - PAYMENT VOUCHER FORM: Page 1 of 1 Version 2.4.8db(02.26.16) FORM: DOE-171 V 2.4.8db(02.26.16) STATE OF NEW JERSEY DEPARTMENT OF EDUCATION - CHIEF OF STAFF OFFICE OF SCHOOL FACILITIES Parent Land Temporary Feasibility Emergent STATE PROJECT#: 4550-050-17-1000 4550-050-17-1200 CONTRACT PROCUREMENT COMPLIANCE CERTIFICATION This Form is for ROD Grant Projects Only County: District Name: District Number: School Name: School Code: UNION ROSELLE PARK BORO 4550 Roselle Park High School 050 District Contact: Contact Title: District Telephone #: District Fax #: District E-Mail: Susan Guercio Business Administrator 908-245-2103 908-245-1226 sguercio@rpsd.org Project Title: Project Address: Municipality: Zip Code: Temporary Classroom Unit at Roselle Park H 185 West Webster Avenue Roselle Park, NJ 07204 A/E Firm: A/E Contact: A/E Phone #: A/E Fax #: A/E E-Mail: DiCara Rubino Architects Jake Sentschak 973-256-0202 973-256-0227 jsentschak@dicararubino.com Brief Description of Project: Provide new Temporary Classroom Unit and all associated equipment. This form to be executed by the District Business Administrator and approved by Board resolution as per N.J.A.C. 6A:26-4.7 By my signature below, I certify that all contracts procured for the above referenced school facilities project conform to the Public School Contracts Law, N.J.S.A. 18A:18A-1 et seq. and any regulations and rules thereunder and all other applicable laws. School Business Administrator (Signature) : School Business Administrator: Date: Susan Guercio Comments/Notes: FOR DOE USE ONLY Signature: Date Acted Upon: Request Reviewed By: Title: Action: APPROVED DENIED (identify reason below) RETURNED NO ACTION (identify reason below) Comments: FORM: DOE-171 - CONTRACT PROCUREMENT COMPLIANCE CERTIFICATION: Page 1 of 1 Version 2.4.8db(02.26.16) FORM: DOE-172 V 2.4.8db(02.26.16) Parent STATE OF NEW JERSEY DEPARTMENT OF EDUCATION - CHIEF OF STAFF OFFICE OF SCHOOL FACILITIES Land Temporary Feasibility Emergent STATE PROJECT#: 4550-050-17-1000 4550-050-17-1200 LIST OF EXECUTED CONTRACTS This Form is for ROD Grant Projects Only County: District Name: District Number: School Name: School Code: UNION ROSELLE PARK BORO 4550 Roselle Park High School 050 District Contact: Contact Title: District Telephone #: District Fax #: District E-Mail: Susan Guercio Business Administrator 908-245-2103 908-245-1226 sguercio@rpsd.org Project Title: Project Address: Municipality: Zip Code: Temporary Classroom Unit at Roselle Park H 185 West Webster Avenue Roselle Park, NJ 07204 A/E Firm: A/E Contact: A/E Phone #: A/E Fax #: A/E E-Mail: DiCara Rubino Architects Jake Sentschak 973-256-0202 973-256-0227 jsentschak@dicararubino.com Brief Description of Project: Provide new Temporary Classroom Unit and all associated equipment. Contract # Contract Type Contract Date Awarded Amount Change orders Adjusted Amount Final Amount Total School Business Administrator (Signature) : School Business Administrator: Request Reviewed By: Title: Action: APPROVED Date: Susan Guercio FOR DOE USE ONLY Signature: Date Acted Upon: DENIED (identify reason below) RETURNED NO ACTION (identify reason below) Comments: FORM: DOE-172 - LIST OF EXECUTED CONTRACTS: Page 1 of 1 Version 2.4.8db(02.26.16) FORM: DOE-173 STATE OF NEW JERSEY DEPARTMENT OF EDUCATION - CHIEF OF STAFF OFFICE OF SCHOOL FACILITIES V 2.4.8db(02.26.16) Parent Land Temporary Feasibility Emergent STATE PROJECT#: 4550-050-17-1000 4550-050-17-1200 CONSTRUCTION PLAN COMPLIANCE CERTIFICATION This Form is for ROD Grant Projects Only County: District Name: District Number: School Name: School Code: UNION ROSELLE PARK BORO 4550 Roselle Park High School 050 District Contact: Contact Title: District Telephone #: District Fax #: District E-Mail: Susan Guercio Business Administrator 908-245-2103 908-245-1226 sguercio@rpsd.org Project Title: Project Address: Municipality: Zip Code: Temporary Classroom Unit at Roselle Park H 185 West Webster Avenue Roselle Park, NJ 07204 A/E Firm: A/E Contact: A/E Phone #: A/E Fax #: A/E E-Mail: DiCara Rubino Architects Jake Sentschak 973-256-0202 973-256-0227 jsentschak@dicararubino.com Brief Description of Project: Provide new Temporary Classroom Unit and all associated equipment. This form to be executed by the District Business Administrator and approved by Board resolution as per N.J.A.C. 6A:26-4.7(b)5. By my signature below, I certify the above referenced project was constructed consistent with the approved plans and specifications for the school facilities project and all approvals provided by the Commissioner pursuant to EFCFA. School Business Administrator (Signature) : School Business Administrator: Date: Susan Guercio Required Attachment: Board Resolution Approving the School Business Administrator's Construction Plan Compliance Certification. Comments/Notes: FOR DOE USE ONLY Signature: Date Acted Upon: Request Reviewed By: Title: Action: APPROVED DENIED (identify reason below) RETURNED NO ACTION (identify reason below) Comments: FORM: DOE-173 - CONSTRUCTION PLAN COMPLIANCE CERTIFICATION: Page 1 of 1 Version 2.4.8db(02.26.16) FORM: DOE-174 V 2.4.8db(02.26.16) Parent STATE OF NEW JERSEY DEPARTMENT OF EDUCATION - CHIEF OF STAFF OFFICE OF SCHOOL FACILITIES STATE PROJECT#: 4550-050-17-1000 Land Temporary Feasibility Emergent 4550-050-17-1200 CHANGE ORDER REQUEST FORM Project and District Information County: District Name: District Number: School Name: School Code: UNION ROSELLE PARK BORO 4550 Roselle Park High School 050 District Contact: Contact Title: District Telephone #: District Fax #: District E-Mail: Susan Guercio Business Administrator 908-245-2103 908-245-1226 sguercio@rpsd.org Project Title: Project Address: Municipality: Zip Code: Temporary Classroom Unit at Roselle Park H 185 West Webster Avenue Roselle Park, NJ 07204 A/E Firm: A/E Contact: A/E Phone #: A/E Fax #: A/E E-Mail: DiCara Rubino Architects Jake Sentschak 973-256-0202 973-256-0227 jsentschak@dicararubino.com Brief Description of Project: Provide new Temporary Classroom Unit and all associated equipment. Existing Contract # Contract Type Contract Date Awarded Amount Prior Approved Change orders C.O. # List of Change Orders Previously Approved for this individual Date Approved By Amount Proposed C.O.# Description Date Awarded Amount Proposed C.O. Amount % of Approved Change Orders C.O. Type (see below) % of Approved C.O. + proposed C.O. Type Change order Types Approvable by District: (For up to 20% of the original contract awarded amount of each individual contract) A Emergencies consistent with N.J.S.A 18A:18A-7; B Unforeseeable physical conditions; or C Minor modifications to project scope that achieve cost savings, improve service or resolve construction conditions. Change order Types that must be approved by DOE: D Change orders that, in the aggregate, increase the amount of the original award of each individual contract, or of the entire project, by greater than twenty percent (20%), but for no more than the approved referendum, including changes funded by project contingency. E Change orders that eliminate or affect the project scope that was the basis of the Division's determination of the final eligible costs of a school facilities project pursuant to N.J.A.C. 6A:26-3.6; or F Change orders that affect the number, size, configuration, location or use of educational spaces. 1) Does the proposed change order affect educational adequacy? If yes, please describe in detail. 2) If educational adequacy is not affected, please describe what was originally approved by DOE and what is being requested. 3) List the costs (additions and/or deductions) associated with this request. Certify only one of the following statements: By my signature below, I certify the availability of funds for the above proposed change order, that the proposed change order affects the final eligible costs of the school facilities project, that no other solution is possible, and that no excess scopes are proposed. District Board Secretary (Signature) : Date: District Board Secretary (Type Name) : By my signature below, I certify the availability of funds for the above proposed change order and that the proposed change order doesn't affect the final eligible costs of the school facilities project (N.J.A.C. 6A:26-4.9). District Board Secretary (Signature) : Date: District Board Secretary (Type Name) : Request Reviewed By: Title: Action: APPROVED FOR DOE USE ONLY Signature: Date Acted Upon: DENIED (identify reason below) RETURNED NO ACTION (identify reason below) Comments: FORM: DOE-174 - CHANGE ORDER REQUEST FORM: Page 1 of 1 Version 2.4.8db(02.26.16) Parent V 2.4.8db(02.26.16) Land Temporary DOE PROJECT TRANSMITTAL TO SDA County: District Name: District Number: School Name: School Code: UNION ROSELLE PARK BORO 4550 Roselle Park High School 050 Project Title: Project Address: Municipality: Zip Code: Temporary Classroom Unit at Roselle Park H 185 West Webster Avenue Roselle Park, NJ 07204 1. District Type: SDA District 55% & over district aid % 2. Submission Category: District managed Project GRANT  STATE PROJECT#: 4550-050-17-1000 4550-050-17-1200 Feasibility Emergent Date: District Contact: Contact Title: District Phone #: District Fax #: District E-Mail: Susan Guercio Business Administrator 908-245-2103 908-245-1226 sguercio@rpsd.org A/E Firm: A/E Contact: A/E Phone #: A/E Fax #: A/E E-Mail: DiCara Rubino Architects Jake Sentschak 973-256-0202 973-256-0227 jsentschak@dicararubino.com Under 55% district aid % Level II District SDA Managed Project Pre Development Land Acquisition Design & Construction Submission Type New Project Submission Additional Information 3. Brief Description of Project: Provide new Temporary Classroom Unit and all associated equipment. 4. Project Context: 5. Project Type(s):  School facilities Project Emergent Project (Check All Applicable) 6. Tier Ranking: New Construction Rehabilitation  Tier I  Tier I Demonstration Project Land Acquisition Energy Service Project Community Provider ECC Tier II Tier II Tier IV Tier IV Tier III Tier III 7. Requested Pre-Development Scope: Temporary Facilities Site Analysis Acquisition of New Site Temporary Classroom (TCU) Acquisition of Add. Parcels Temporary Leased Space District Owned Land Temporary Leased Facility Acquisition of Temporary Facility 8. Project Scope: New Construction: New Building Replacement Addition Acquisition of Existing Building Feasibility Study Rehabilitation: Renovation Alterations Pre-Design services: Ed. Spec./Programming Schematic Design Capital Maintenance Rehabilitation w/Building Acquisition 9. Temporary Facilities: Purpose of Temporary Facilities: Swing Space Early Childhood-in advance of permanent construction To House Excess enrollment-in advance of permanent construction 10. Attachments to This Transmittal: For Grant Projects: PEC Letter FEC Letter Board Resolution Land Approval Letter Project Cost Estimate Final Ed. Adequacy Letter Final Project Report FEC Letter Preliminary Project Report PEC Letter For SDA Managed Projects: Pre-Development Letter Site (Block & Lot) Proposed Room Inventory Submitted/Reviewed By (DOE): Final Ed. Adequacy Approval (For DOE Use Only) Prepared By DOE Manager: Approved By DOE Reg. Director: DOE Signature DOE-180 - DOE PROJECT TRANSMITTAL TO SDA: Page 1 of 1 Version 2.4.8db(02.26.16) County: UNION District: 0 V 2.4.8db(02.26.16) ROSELLE PARK BORO Temp. Fac. Sub-Project #: School: Roselle Park High School 4550-050-17-1200 County: District Name: District #: School Name: School Code: UNION ROSELLE PARK BORO 4550 Roselle Park High School 50 District Contact: Contact Title: District Tel #: District Fax #: District E-Mail: Susan Guercio Business Administrator 908-245-2103 908-245-1226 sguercio@rpsd.org Project Title: Project Address: Municipality: Zip Code: DOE Manager: Temporary Classroom Unit at Ros 185 West Webster Avenue Roselle Park, NJ 07204 A/E Firm: A/E Contact: A/E Phone #: A/E Fax #: A/E E-Mail: DiCara Rubino Architects Jake Sentschak 973-256-0202 973-256-0227 jsentschak@dicararubino.com Project Type: Project Scope:  School Facilities Project  Other Capital Project (no state funding) Emergent Project ! Community Provider Early Childhood Facility School Facilities Requested as Demonstration Project Land Acquisition Disposal of Land Request Closing of School Facility Request Energy Service Project New Construction Component (if applicable): New School (if also Land Purchase, see also 2d below) Replacement School (with disposal/demolition of existing school) New Wing or Bldg Add'n, and/or Partial Demolition/Replacement Acquisition of Existing Educational Facility Acquisition of, Construction of, or Add'n to a Non-Educ'l Facility Temporary Space Component (if applicable): For Educational Purposes For Non-Educational Purposes QC Review: Completed by: Date: Released to manager W/O QC review PEC (Preliminary Eligible Cost) Approval: (Educational Specifications and Schematic Drawings) Itemized list of furniture / equipment with areas Proposed Room Inventory Report (from approved LRFP) Cohort-Survival Enroll Projection (within one year) Date: Temporary Facilities Checklist DOE-126 Other Capital Projects, BOE Resolution - board not seeking funding Demonstration Project, DOE 121 LEED statement (New School only) Pre-Development Service Request (Abbott & >55% Only) DOE-110 Feasibility Study Variance Approval Request, DOE-125 Copy of letter to Local Planning Board Date Submitted: 55 days = Functional Capacity Worksheet (Not required) Pre-Development Service Approval Letter PEC Letter Other Capital Project Letter Version 2.4.8db(02.26.16) Date: Date: Date: Feas. Sub-project #: Proje 0 Emergen District Type: SDA District 55% and over District Aid %  Regular Operating District Private School for Disabled Level II (Project must be undertaken by SDA) Status of District's LRFP: Draft Determination issued Final Determination issued LRFP previously amended LRFP Incomplete Date: Date: Latest Date 1/0/19 1/0/19 1/0/19 Renovation/Alteration Construction Component (if applic Educational: Alteration of any educational space Non-Educational: Impacts only Non-Educ'l space/system/ Educational: Change-of-Use that requires Alterations, or t Mech. or Elec. changes per NJAC 5:23 or NJAC 6A:26. Site or Facility Change or other Alteration For Barrier Free 5:23, Sec. 504 of Federal Rehabilitation Act and ADA Act Land Acquisition Component (if applicable): Acquire new site or additional parcels to expand an existi Checklist was sent to applicant NOTES: FEC (Final Eligible Cost) Approval: FEC letter Date: PEC Letter Attachment "A" received Board resolution signed and sealed authorizing the district's elections SDA Transmittal, Date: Final Report & FEC Cost Recommendation (SDA Projects) Local Release for Authority Projects & DCA if non-authority Project DOE 124 DCA Transmittal Date: FEA (Final Educational Adequacy Approval): Fee Paid Date: Amount: Check#: 3 copies of final drawings signed & sealed (If required) SDA Transmittal, Date: DCA Transmittal (FEA letter) FEA Letter Date: Manager's Releas signature: ect No. 4550-050-17-1000 0 nt Sub-project #: Impact on Educational Review:  Educational Non-Educational Referendum Statutes: 900 900 900 Passed Defeated cable): /site that requires e, per NJAC t. ng site se to Archives: date: Version 2.4.8db(02.26.16)