"The Americans With Disabilities Act Consultation Process Form" - Massachusetts

The Americans With Disabilities Act Consultation Process Form is a legal document that was released by the Secretary of the Commonwealth of Massachusetts - a government authority operating within Massachusetts.

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The Commonwealth of Massachusetts
William Francis Galvin, Secretary of the Commonwealth
Massachusetts Historical Commission - State Historic Preservation Office
The Americans with Disabilities Act Consultation Process Form
Name of Property: __________________________________________________________________________
Address of Property: Street: __________________________________________________________________
City: ____________________________ County: ____________ State: _______________Zip: ______________
Historic Designation/Status/Listing:
National Historic Landmark
Date of Listing _______________
Listed Individually in National Register of Historic Places
Date of Listing _______________
Located in registered historic district (specify ___________________ )
Date of Listing _______________
Listed in State Register of Historic Places
Date of Listing _______________
Eligible for listing (prepare and submit MHC inventory form, attach to application)
Project Contact:
Name: ___________________________________________________________________________________
Street: ______________________________________________City: _________________________________
State: _______ Zip: ________________ Daytime Telephone Number: _________________________________
Property Owner:
Name: ___________________________________________________________________________________
Street: ______________________________________________City: _________________________________
State: _______ Zip: ________________ Daytime Telephone Number: _________________________________
Signature: _________________________________________________________________________________
(over) (R3)
The Commonwealth of Massachusetts
William Francis Galvin, Secretary of the Commonwealth
Massachusetts Historical Commission - State Historic Preservation Office
The Americans with Disabilities Act Consultation Process Form
Name of Property: __________________________________________________________________________
Address of Property: Street: __________________________________________________________________
City: ____________________________ County: ____________ State: _______________Zip: ______________
Historic Designation/Status/Listing:
National Historic Landmark
Date of Listing _______________
Listed Individually in National Register of Historic Places
Date of Listing _______________
Located in registered historic district (specify ___________________ )
Date of Listing _______________
Listed in State Register of Historic Places
Date of Listing _______________
Eligible for listing (prepare and submit MHC inventory form, attach to application)
Project Contact:
Name: ___________________________________________________________________________________
Street: ______________________________________________City: _________________________________
State: _______ Zip: ________________ Daytime Telephone Number: _________________________________
Property Owner:
Name: ___________________________________________________________________________________
Street: ______________________________________________City: _________________________________
State: _______ Zip: ________________ Daytime Telephone Number: _________________________________
Signature: _________________________________________________________________________________
(over) (R3)
Consultation with individuals with disabilities and their organizations:
Name: ___________________________________________________________________________________
Organization: ______________________________________________________________________________
Street: ______________________________________________City: _________________________________
State: _______ Zip: ________________ Daytime Telephone Number: _________________________________
Signature: _________________________________________________________________________________
Attach comments to form.
Consultation with local historical commission
Name: ___________________________________________________________________________________
Organization: ______________________________________________________________________________
Street: ______________________________________________City: _________________________________
State: _______ Zip: ________________ Daytime Telephone Number: _________________________________
Attach comments to form.
Describe major significant architectural features of property. Include the overall shape of the
building, its materials, craftsmanship, decorative details, interior space and features, as well as
various aspects of its site and environment.
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
Explain why applying the General Requirements for Barrier Free Access would threaten or
destroy the historic significance of the property.
Architectural feature(s): ______________________________________________________________________
Approximate date(s) of feature(s): _______________________________________________________________
Describe existing condition(s): _________________________________________________________________
Describe the proposed alternative Barrier Free Access solution under the Special Rule
[4.1.793)]. Include photographs, drawings, and all pertinent information to assist us in our
review.
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
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