Fill - Free fillable Building (Commonwealth of Massachusetts) PDF form

CHARLES D. BAKER

GOVERNOR

Co

mmonwealth of Massachusetts

Division of Professional Licensure

Office of Public Safety and Inspections

Architectural Access Board

1000 Washington St., Suite 710 • Boston • MA • 02118

V: 617-727-0660 • www.mass.gov/aab • Fax: 617-979-5459

EDWARD A. PALLESCHI

UNDERSECRETARY OF

CONSUMER AFFAIRS AND

BUSINESS REGULATION

KARYN E. POLITO

LIEUTENANT GOVERNOR

DIANE M. SYMONDS

COMMISSIONER, DIVISION OF

PROFESSIONAL LICENSURE

MIKE KENNEALY

SECRETARY OF HOUSING AND

ECONOMIC DEVELOPMENT

Docket Number: ______________ddd

(Staff Use Only)

GENERAL BUILDING 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 address of the building believed to be in violation of the Rules and

Regulations of this Board?

Building Name or Description:

__________________________________________________________________

Street Address:

__________________________________________________________________

City/Town:

__________________________________________________________________

2. Does it appear that the building was recently constructed or renovated? ________________

3. What date were you most recently at the building? ____________

4. How many floors? ____________

Page 2 of 4 Rev, 1/2019

5. Please describe the violation(s) as clearly as possible. Include information on the nature of

the violation, the location of the violation within the building or site, and any other information

you feel might be relevant. The Board’s staff also recommends you include photographs of

the violation if possible. (Please use additional sheets if necessary):

_________________________________________________________________________________________

NOTE: Separate forms are available for complaints on Curb Cuts, Handicap Parking

Spaces, Public Telephones, and Housing. Please call the office and request one or more

forms.

Page 3 of 4 Rev, 1/2019

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 the building owner or manager:

Name: _______________________________________________________________

Mailing Address:

_____________________________________________________________________

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.

c.

1.) Do you have reason to believe the element(s) subject to this complaint have been

recently renovated?

Yes: _____ No: _____

If you answered yes, please indicate the date and extent of the work below, and if

possible attach a copy of the associated building permit to this complaint.

______________________________________________________________________

Continued on Next Page

Page 4 of 4 Rev, 1/2019

2.) Do you have reason to believe that in any continuous 3-year period the spending on

construction, reconstruction, alteration, or remodeling was more than:

$100,000 ______

30% of the building’s assessed value ______

If you answered yes, please indicate the date and extent of the work below, and if

possible attach a copy of the associated building permit to this complaint.

______________________________________________________________________

Assessed value of the building only (do not include the value of the land):

______________________________________________________________________

If possible, please attach a copy of the property card to your complaint.

6. 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):

Name: ___________________________________________________________________

Mailing Address:

_________________________________________________________________________

E-mail:___________________________________________________________________

Telephone:________________________________________________________________

7. Individual Signature (required):________________________________________________

Date: ____________________

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