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CITY OF MODESTO DISABLED ACCESS DECLARATION WORKSHEET PROJECT ADDRESS: PERMIT NO. APPLICANT’S NAME: PHONE NO. 1. The total cost of all construction contemplated for this project. $ 2. I certify that the existing building and site comply 100% with current State Title 24 Disabled Access Standards YES If the answer is YES, sign NO If the answer is NO, complete the remainder of this form and date below Item No. 6 and include it with your Building Permit Application submittal 3. The following is a list of costs to provide access features in order to comply 100% with the current State Title 24 Disabled Access Standards. (All costs to be documented by actual bids or other information accepted by the Building Official.) a. The cost of providing a primary entrance. (Including but not limited to, a level threshold, $ landings, door hardware, maximum door pull, etc.) b. The cost of providing the primary path of travel to the specific area of alteration, structural $ repair, or addition. c. The cost of providing accessible restroom facilities. (If this item puts you above the 20% $ figure, provide a complete breakdown for each restroom.) d. The cost of providing an accessible drinking fountain. (If required or if a drinking fountain $ is present.) e. The cost of providing accessible public telephones. (If public telephones exist.) $ f. The cost of providing path of travel to the main entrance, including but not limited to, $ signage, parking, loading/unloading, ramps, and walks. 4. The total cost listed under item No. 3. $ • Item No. 4 is less than or equal to 20% of Item No. 1 YES NO If No: please indicate in Item No. 5 how you will spend 20% of Item No. 1 toward accessibility. 5. I agree to allocate 20% of the total cost in expenditures for the following access features: a. An accessible entrance $ b. An accessible route to the remodeled area $ c. At least one accessible restroom for each sex $ d. Accessible telephones $ e. Accessible drinking fountains $ f. Path of travel, parking, storage, and alarms $ 6. Give description of scope of work to provide the access features identified in Item No. 5. Signature: Date: BUILDING SAFETY DIVISION USE ONLY In accordance with Title 24, CBC, Section 1134B, this request is: Approved Disapproved Signature: Date: