The Commonwealth of Massachusetts Office of Public Safety and Inspections Architectural Access Board One Ashburton Place, Room 1310 Boston Massachusetts 02108-1618 Phone: 617-727-0660 Fax: 617-727-0665 www.mass.gov/dpl/aab 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, 07/10