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)

HOUSING 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 EXACT address of the building believed to be in violation of the Rules and Regulations of this Board:
	Name: __________________________________________________________________
	Address: ________________________________________________________________
	City or Town: _____________________________________________________________


2.	What is the building use (please check one or more)?
	
	a. Transient Lodging Facility (temporary accommodations)
____Hotel, Motel, Inns	____Dormitory	____Halfway House
____Bed & Breakfast	____Resort	____Transitional Housing
____Boarding House	____Homeless Shelter	____Other: _______________
	
	b. Multiple Dwelling (Lodging or Residential Facility)
____Shelter	____Apartment
____Hospice	____Condominium
____Group Home	____Assisted Living
____Congregate Living Facility	____Cooperative
____Other: _______________	____Other: _______________

c. What type (Please check one):	Hire___	Rent___	Lease___	Sale___


3.	How many units per building: _______	Total number of units in complex: ___________
	How many floors in a building: ______	Total number of buildings in complex: ________


4.	When was the building constructed or renovated? _________________________________
	

5.	When was the most recent date you observe the violation(s)? ________________________


6.	Please cite each section of the Board's regulations that you believe is being violated, then describe each section, as specifically as possible, in the space below. (Please use additional sheets if necessary):
	_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

	NOTE: Separate forms are available for complaints on Buildings, Curb Cuts, Handicap Parking Spaces, and Public Telephones. Please call the office and request those 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 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(S) 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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