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 In accordance with M.G.L., c.22, § 13A, I hereby apply for modification of or substitution for the rules and regulations of the Architectural Access Board as they apply to the building/facility 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) If you are a tenant seeking variance(s), a letter from the owner of the building authorizing you to apply on his or her behalf is required. 3) 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 building/facility: __________________________________________________________________________________________________________________________________________________ E-mail:___________________________________________________________________ Telephone:________________________________________________________________ 2. State the name and address of the building/facility: _________________________________________________________________________ _________________________________________________________________________ 3. Describe the facility (i.e. number of floors, type of functions, use, etc.): _________________________________________________________________________ __________________________________________________________________________________________________________________________________________________ _________________________________________________________________________ 4. Total square footage of the building: ___________________Per floor:_________________ a. total square footage of tenant space (if applicable):_______________________________ 5. Check the work performed or to be performed: ___ New Construction ___ Addition ___ Reconstruction/Remodeling/Alteration ___ Change of Use 6. Briefly describe the extent and nature of the work performed or to be performed (use additional sheets if necessary): __________________________________________________________________________________________________________________________________________________ 7. State each section of the Architectural Access Board's Regulations for which a variance is being requested: 7a. Check appropriate regulations: _____1996 Regulations _____ 2002 Regulations _____2006 Regulations SECTION NUMBER LOCATION OR DESCRIPTION __________________ _________________________________________________ __________________ _________________________________________________ __________________ _________________________________________________ __________________ _________________________________________________ __________________ _________________________________________________ 8. Is the building historically significant? ____yes _____no. If no, go to number 9. 8a. If yes, check one of the following and indicate date of listing: ____________ National Historic Landmark ____________ Listed individually on the National Register of Historic Places ____________ Located in registered historic district ____________ Listed in the State Register of Historic Places ____________ Eligible for listing 8b. If you checked any of the above and your variance request is based upon the historical significance of the building, you must provide a letter of determination from the Massachusetts Historical Commission, 220 Morrissey Boulevard, Boston, MA 02125. 9. 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. ________________________________________________________________________________________________________________________________________________________________________________________________________________________ 10. Has a building permit been applied for? ________________________________________ Has a building permit been issued? ___________________________________________ 10a. If a building permit has been issued, what date was it issued? _________________ 10b. If work has been completed, state the date the building permit was issued for said work: ___________________________________________________________________ 11. State the estimated cost of construction as stated on the above building permit: ________________________________________________________________________ 11a. If a building permit has not been issued, state the anticipated construction cost: ________________________________________________________________________ 12. Have any other building permits been issued within the past 36 months? ______________ 12a. If yes, state the dates that permits were issued and the estimated cost of construction for each permit: ________________________________________________ 13. Has a certificate of occupancy been issued for the facility?_________________________ If yes, state the date: _____________________________ 14. To the best of your knowledge, has a complaint ever been filed on this building relative to accessibility? _____ yes _____no 15. State the actual assessed valuation of the BUILDING ONLY, as recorded in the Assessor's Office of the municipality in which the building is located: ________________ Is the assessment at 100%? _____________ If not, what is the town's current assessment ratio?_______________ 16. State the phase of design or construction of the facility as of the date of this application:______________________________________________________________ 17. 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 facility: ________________________________________________________________________________________________________________________________________________E-mail:__________________________________________________________________ Telephone:_______________________________________________________________ 18. State the name and address of the building inspector 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 5 Rev, 08/12