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? ____________
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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):
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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.
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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
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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: ____________________