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200 S. Anaheim Blvd., Suite 145 Anaheim, California 92805 (714)765-5153 Phone (714)765-4607 Fax www.anaheim.net/building OCT 2013 B716 FOR OFFICE USE ONLY CITY OF ANAHEIM PLANNING DEPARTMENT BUILDING DIVISION DOCUMENTATION OF UNREASONABLE HARDSHIP FORM Processing Fee: $186.18/hr. (1 hr. min.) Payment Verified by: (For projects with construction cost of alterations, structural repairs, or additions less than $132,536.28 CBC 1134B2.1) Project Address: Plan Review Owner: Phone # : E-mail: Applicant: Phone # E-mail: I HEREBY REQUEST AN EXEMPTION FROM FULL COMPLIANCE WITH CBC SEC. 1134 B; ACCESSIBILITY FOR EXISTING BUILDINGS. I UNDERSTAND THE AREA OF REMODEL SHALL COMPLY WITH DISABILITY ACCESS REGULATIONS AND IS NOT COVERED BY THIS REQUEST. The following information is provided to assist in determination of unreasonable hardship (Please answer all items): 1. Facility used by the general public for the purpose of: 2. The cost of all contemplated construction is: $ 3. The cost of installing additional access features not originally planned, but required by code: $ 4. The additional access feature increases the cost of construction by: % (b a) 5. The financial impact of installing the additional features for this project is: ---PAGE BREAK--- PAGE 2 OF 2 B716 200 S. Anaheim Blvd., Suite 145 Anaheim, California 92805 (714)765-5153 Phone (714)765-4607 Fax www.anaheim.net/building TO BE COMPLETED BY THE PETITIONER PARTIAL COMPLIANCE Identify and provide the accessibility features outside the area of remodel which are not originally planned and shown on the submitted plan. Provide an estimate of the cost of compliance for each provided item. The priority for these provided items shall be in the order listed below: [ ] Path of travel to the entrance $ [ ] Accessible route to the altered area $ [ ] One accessible restroom for each sex $ [ ] Accessible telephones $ [ ] Accessible drinking fountain(s) $ [ ] Additional parking $ [ ] Other: $ [ ] $ * The cost must equal or exceed 20% of TOTAL $ * INDEMNITY I/We, the undersigned, as applicants for an exemption from full compliance with the provisions of CBC Sec. 1134 B; Accessibility for Existing Buildings, represent that I/We are familiar with the provisions of that section and that this project fully qualifies for the requested exemption(s). In the event this exemption is granted, I/We do hereby indemnify and hold harmless the City of Anaheim and its officers and employees from any and all claims, liability, and lawsuits arising from the grant of this exemption and the building of the project pursuant thereto. Date: Applicant Date: Applicant Division Action: ( ) Approved ( ) Denied Name Title Date Conditions of Approval: