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)
REQUEST FOR ADJUDICATORY HEARING

RE:__________________________________________________________________________________Name and address of building as appearing on application for variance

I, _____________________________________, do hereby request that the Architectural Access Board conduct an informal Adjudicatory Hearing in accordance with the provisions of 801 CMR Rule 1.02 et. seq. as I am aggrieved by the decision of the Board with respect to Section(s) _______________________
of the Rules and Regulations of the Architectural Access Board, 521 CMR.
I understand that I may request such a hearing within thirty (30) days of receipt of the Notice of Action.

Date:________________			_________________________________________________
Signature
							

PLEASE PRINT:				_________________________________________________
Name

_________________________________________________
Address

_________________________________________________
City/Town	State	Zip Code

_________________________________________________
E-mail

_________________________________________________
Telephone
PLEASE NOTE:
This form must be received by the Board within thirty (30) days after receipt of the Notice of Action.
Rev, 01/10