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) APPLICATION FOR VARIANCE Curb cuts/sidewalks In accordance with M.G.L., Chapter 22, Section 13A, I hereby apply for modification of or substitution for the rules and regulations of the Architectural Access Board as they apply to the location(s) described below on the grounds that literal compliance with the Board's regulations is impracticable in my case. PLEASE ENCLOSE: 1) A filing fee of $50.00 (Check/Money Order) made payable to the “Commonwealth of Massachusetts” and all supporting documentation (e.g. plans in 11” x 17” format, photographs, etc.). In addition, the complete package (including plans, photographs and the completed “Service Notice”) must be submitted to all parties via compact disc. 2) The completed “Service Notice” form provided at the end of this application certifying that a copy of your complete application has been received by the Local Building Inspector, Local Disability Commission (if applicable), and Local Independent Living Center for the city/town that the property in question resides in. A list of the local entities can be found by calling the Architectural Access Board Office or the Local City/Town Clerk. For a list of the Local Independent Living Centers you can either call the Architectural Access Board Office or visit the Massachusetts Statewide Independent Living Council website at http://www.masilc.org/membership/cils. 1. State the name and address of the owner of the project: __________________________________________________________________________________________________________________________________________________E-mail:___________________________________________________________________ Telephone:________________________________________________________________ 2. State the exact location of the area in question (e.g. Northwest corner of Main St. and Broadway) (use additional sheets if necessary): _________________________________________________________________________ _________________________________________________________________________ 3. Describe the project (e.g. complete reconstruction of Rt. 20 from Main St. to Broadway): _________________________________________________________________________ 4. Check the work performed or to be performed: _____New Construction _____Reconstruction/Alteration _____Repair 5. Briefly describe the extent and nature of the work performed or to be performed (use additional sheets if necessary): __________________________________________________________________________________________________________________________________________________ 6. State each section of the Architectural Access Board's Regulations for which a variance is being requested: 6a. Check appropriate regulations: _____1996 Regulations _____2002 Regulations _____2006 Regulations SECTION NUMBER LOCATION OR DESCRIPTION __________________ _________________________________________________ __________________ _________________________________________________ __________________ _________________________________________________ __________________ _________________________________________________ 7. For each variance requested, state in detail the reasons why compliance with the Board’s regulations is impracticable (use additional sheets if necessary), including but not limited to: the necessary cost of the work required to achieve compliance with the regulations (i.e. written cost estimates); and plans justifying the cost of compliance. ___________________________________________________________________________________________________________________________________________________________________________________________________________________________ 8. Has the project been out bid?________________________________________________ Has the contract been awarded?_____________________________________________ 8a. If the contract has been awarded, what date was it awarded? ___________________________________________________________________ 8b. Has the project been completed? ___________________________________________________________________ 8c. If work has been completed, state the date work began: ___________________________________________________________________ Completion date:_____________________________________________________ 9. State the estimated cost of the total project:_____________________________________ 10. Has any other work been performed at this location within the past 36 months?_________ 11. Is this project funded by the Massachusetts Department of Transportation?____________ 12. Has the project been accepted by the City or Town?______________________________ If yes, state the date that the project was accepted:______________________________ 13. To the best of your knowledge, has a complaint ever been filed on this project relative to accessibility? _______yes ________no 14. State the name and address of the architectural or engineering firm including the name of the individual architect or engineer responsible for preparing drawings of the project: ________________________________________________________________________________________________________________________________________________E-mail:__________________________________________________________________ Telephone:_______________________________________________________________ 15. State the name and address of the local or state building official responsible for overseeing this project: ________________________________________________________________________________________________________________________________________________E-mail:__________________________________________________________________ Telephone:_______________________________________________________________ Date:________________ ___________________________________________ Signature of owner or authorized agent PLEASE PRINT: ___________________________________________ Name ___________________________________________ Address ___________________________________________ City/Town State Zip Code ___________________________________________ E-mail ___________________________________________ Telephone ARCHITECTURAL ACCESS BOARD VARIANCE APPLICATION SERVICE NOTICE I, __________________________________________, as_________________________________ for the Petitioner ________________________________________________________submit a variance application filed with the Massachusetts Architectural Access Board on ________________ 20 _____. HEREBY CERTIFY UNDER THE PAINS AND PENALTIES OF PERJURY THAT I SERVED OR CAUSED TO BE SERVED, A COPY OF THIS VARIANCE APPLICATION ON THE FOLLOWING PERSON(S) IN THE FOLLOWING MANNER: NAME AND ADDRESS OF PERSON OR AGENCY SERVED METHOD OF SERVICE DATE OF SERVICE 1 2 3 AND CERTIFY UNDER THE PAINS AND PENALTIES OF PERJURY THAT THE ABOVE STATEMENTS TO THE BEST OF MY KNOWLEDGE ARE TRUE AND ACCURATE. ________________________________________________________________________________ Signature: Appellant or Petitioner On the _____________________ Day of ___________________________ 20 ________________ PERSONALLY APPEARED BEFORE ME THE ABOVE NAMED ________________________________________________________________________________ (Type or Print the Name of the Appellant) ________________________________ _______________________________ NOTARY PUBLIC MY COMMISSION EXPIRES Page 1 of 4 Rev, 08/12