The Commonwealth of Massachusetts
Department of Public Safety
Architectural Access Board
One Ashburton Place, Room 1310
Boston Massachusetts 02108-1618
Phone: 617-727-0660
Fax: 617-727-0665
www.mass.gov/dps





Docket Number


____________
(Office Use Only)


GENERAL BUILDING COMPLAINT FORM


PLEASE BE ADVISED THAT THIS FORM IS A MATTER OF PUBLIC RECORD AND WILL BE DISCLOSED UPON REQUEST.

1.	What is the name and address of the building believed to be in violation of the Rules and Regulations of this Board?
	Name: __________________________________________________________________
	Address: ________________________________________________________________
	City/Town: _______________________________________________________________


2.	What is the use of the building (please check one or more)?
	____Retail Establishment	____Transient Lodging Facility	____Multiple Dwelling ____Commercial Building	____Educational Facility	____Medical Care Facility ____Place of Assembly	____Detention Facility	____House of Worship
	____Restaurant	____Transportation Terminal	____Recreational Facility


3.	Does it appear that the building was recently constructed or renovated? ________________


4.	What date were you most recently at the building? ____________


5.	How many floors? ____________


6.	Please check the appropriate section(s) of the Board's regulations that you believe is being violated, then describe each section, as specifically as possible, in the space below. Please note that section numbers are from the 2006 Regulations. The section numbers are listed for your reference. (Please use additional sheets if necessary):

Sections

___ 24  Ramps	
___ 25  Entrances	
___ 26  Doors	
___ 27  Stairs

___ 28  Elevators
___ 29  Floors
___ 30  Toilets
___ 31  Bathing

___ 32  Kitchens
___ 33  Dressing
___ 34  Storage
___ 35  Tables

___ 36  Fountains
___ 38  ATM's
___ 39  Controls
___ 40  Alarms
___ 41  Signage

	________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

	NOTE: Separate forms are available for complaints on Curb Cuts, Handicap Parking Spaces, Public Telephones, and Housing. Please call the office and request one or more forms.

OPTIONAL INFORMATION

The following information is optional, and your complaint will be processed regardless of whether or not the information is provided. However, you should be aware that the less information that is provided, the longer it will take this office to process your complaint.

a.	Name and address of the building owner or manager:___________________________
	_____________________________________________________________________

b.	The Board only considers complaints with respect to buildings which are:
	1.) constructed by the state, city or town, and construction, reconstruction, alteration or remodeling occurred after December of 1968; or
	2.) privately financed buildings that are open to or used by the public and construction, reconstruction, alteration or remodeling occurred after June 10, 1975.
	
	The following information may be obtained by contacting the Local Building Department
	DATE BUILDING PERMIT(S) WAS ISSUED: __________________________________
	ESTIMATE COST(S) OF CONSTRUCTION: __________________________________

c.	The assessed value of the building will determine the extent that a building must comply. You may obtain the assessed value of the building by contacting the Local Assessor's Office.
	ASSESSED VALUE OF THE BUILDING AT TIME PERMIT WAS ISSUED: ______________________________________________________________________


7. 	Name and address of person/organization filing this complaint (if organization is filing, please provide the Board with the name of a contact person) (required):________________
	_________________________________________________________________________
	E-mail:___________________________________________________________________
	Telephone:________________________________________________________________

8.	Individual Signature (required):________________________________________________
	Date: ____________________
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