Application Requesting Reasonable Accommodation

It is the policy of the jurisdiction, pursuant to the federal Fair Housing Amendments Act of 1988 and the Massachusetts Fair Housing act, G.L. Chapter 151B, to provide individuals with disabilities reasonable accommodation in rules, policies, practices and procedures to ensure equal access to housing and facilitate the development of housing for individuals with disabilities. This article establishes a procedure for making request for reasonable accommodation in land use, zoning and building regulations, policies, practices and procedures of the jurisdiction to comply fully with the intent and purpose of fair housing laws.

In order to make housing available to an individual with a disability, any eligible person as defined in Section 7-133 of the City Ordinance may request a reasonable accommodation in land use, zoning and building regulations, policies, practices and procedures. Requests for reasonable accommodation shall be in writing and provide the following information (if the question is not applicable, please put "NA"):

1) Applicant or Agent Signature

Statement

As the *, I make the following representations: The information supplied on and with this application form is accurate to the best of my knowledge.

Electronic Signature of Applicant or Agent*

First NameMiddle Name or InitialLast Name

Digital Signature Attestation*

* I hereby attest that my typed electronic signature on this document constitutes the legal equivalent of my manual signature.

Date Signed by Applicant or Agent*

MonthDayYear

2) Property Information

Street Address(es)*

Zoning District(s)*

Overlay District(s), If Any

Ward*

Assessor's:*

MapBlockLot

If there are multiple MBLs, please list them here:

Applicant's Name(s)*

Complete Mailing Address*

Phone Number(s)*

Email*

example@example.com

Property Owner's Name(s)*

Complete Mailing Address*

Phone Number(s)*

Email

example@example.com

Agent's Name (Optional)

Complete Mailing Address

Phone Number(s)

Email

example@example.com

3) Current Actual Use of the Property

Briefly describe the existing structure(s) and/or use(s):*

4) Basis for the Claim

Please describe the basis for the claim that the individual(s) is considered disabled under the federal Fair Housing Amendments Act of 1988 and the Massachusetts Fair Housinq Act, G.L. Chapter 151 B.*

5) Requested Accommodation

Please describe the requested accommodation and the regulations(s) of the Somerville Zoning Ordinance, policy or procedure for which accommodation is sought.*

6) Reasoning for Requested Accommodation

Please describe the reason that the requested accommodation may be necessary for the individual(s) with the disability to use and enioy the dwelling and how the proposed accommodation would benefit persons with a disability.*

7) Number of Residents and Use of the Accommodation

Please specify the maximum number of residents you propose to occupy the facility now or in the future. If the facility has more than one unit, please specify the number of units and the number of residents in each unit that will be using this accommodation.*

8) Additional Information

Is there a house manager that is one of the residents of the facility and is involved in the operation of the facility?*

YesNo

Alternatively, is there an operator involved in the operation of the facility but does not live in the facility?*

YesNo

Does the facility receive financial or other support from a governmental agency?*

YesNo

Is the facility licensed or registered with a governmental agency?*

YesNo

How many residents will have a vehicle at the property/ site/ facility?*

How many off-street parking spaces are available at the property/ site/ facility?*

9) Other Supportive Information

Please include plans, pictures, copies of memoranda, correspondence or background information to assist OSPCD Staff in reaching a decision regarding the need for the accommodation and to facilitate proper consideration of the request that is consistent with fair housing laws.

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Optional Description/Explanation of Uploaded Background Information

Statement

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