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)

SIDEWALK COMPLAINT FORM
Section 22, 521 CMR


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

1.	List the name of the street/intersection believed to be in violation of the Rules and Regulations. Please give EXACT street locations. (Use separate forms for each street/intersection)
	Address: ______________________________________________________________
	City/Town: _____________________________________________________________


2.	In order for the Board to take action on the complaint, the following work must have been completed or in the process of being performed. Please check where appropriate:

____	Sidewalks are currently under construction, repair, or reconstruction.
____	Sidewalks have been repaired, reconstructed, or constructed on:
		____ between June 10, 1975 - August 31, 1996. 
		Approximate date: _______________
		____ after September 1, 1996.


3. Please check the following items that you believe are in violation, and identify the location of the violation by the closest street address or telephone pole number:
	
	____	Width of walkway(s) is less than 48 inches, excluding curb stones. (Section 22.2)

		_________________________________________________________
	
	____	Unobstructed path of travel is less than 36 inches clear, excluding curbstones. (Section 22.2)

	_________________________________________________________


	____	Walkway has a slope greater than 1:20 (5%). (Section 22.3)

	_________________________________________________________

	____	Cross slope of walkway exceeds 1:50 (2%). (Section 22.3.1)
		_________________________________________________________

	____	Walkway has changes in level greater than ¼ inch. (Section 22.4)
		_________________________________________________________

	____	Sidewalk has pooling of water, accumulation of ice, or flow of water across the walkway. (Section 22.6)

	_________________________________________________________

	____	Grating located in the walkway surface has spaces greater than ½ inch wide in the direction of the flow of travel. (Section 22.7)
		_________________________________________________________

	____	Walkway crosses or joins a street, public way, driveway, or parking lot and does not blend to a common level with a slope no greater than 1:20 (5%) or a curb cut is not provided. (Section 22.8.1)
		_________________________________________________________

	____	Other (please specify):_______________________________________


4. What was the most recent date you observed the violation? _______________


5.	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: _____________________________________________________
	

6.	Individual Signature (required):_____________________________________

	Date: _______________________
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