Application Form Disability And Communication Access Board - Hawaii
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1
2Docket: DCAB
____
APPLICATION FORM
DISABILITY AND COMMUNICATION ACCESS BOARD
919 Ala Moana Boulevard, Room 101, Honolulu, HI 96814, V/TTY: (808) 586-8121; Fax: (808) 586-8129
Date: ______________________________
Applicant Information
Company:
Agency/Department: ___________________________________
______________________________
Address:
__________________________________________________________________________________________
City:
State: ___________
Zip:
______________________
______________________________________
Contact:
Phone:
________________________________________________________
______________________
Title:
Fax:
________________________________________________________
______________________
Request Information
Site Specific Alternate Design
Interpretive Opinion
Design Specification (choose one):
❏
❏
❏
ADOPTION ❏ AMENDMENT ❏ REPEAL
❏
Guidelines:
Section(s): _____________________________________
__________________________________________
Description:
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
Site Specific Alternate Design
Project Title:
__________________________________________________________________________________________
__________________________________________________________________________________________
Job No.:
T.M.K.: _________________________________________
_________________________________________
Agency:
__________________________________________________________________________________________
Address:
County:
_______________________________________________________________
_____________
Contact:
Phone:
_______________________________________________________________
_____________
Title:
Fax:
_______________________________________________________________
_____________
I hereby certify that all statements in this application are true and correct to the best of my knowledge, and I agree
and understand that any misstatements of material facts herein may be grounds for site specific alternate design
denial. I understand that all costs related to the processing of this application for a site specific alternate design by
the Disability and Communication Access Board (DCAB), including processing fees, proceeding costs and legal
notice publications, will be billed directly to me. In addition, I agree to submit all public notices to DCAB for review,
approval and filing for publication. Further, I understand that all materials filed with or presented to DCAB will be
retained and will be considered public documents under HRS §92F and shall be available for inspection by the
public during public hearing as well as after a final decision is made.
Signature: __________________________________________________
Date: _______________________
Please see reverse side for additional instructions on how to complete this form.
(REVISION 06/11)
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