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HRS
103-50 DOCUMENT TRANSMITTAL FORM The Department/Agency or Design Consultant submitting
plans under HRS 103-50 should
complete and submit this form with the plans to: Disability
and Communication Access Board 919
Ala Moana Blvd., Room 101 Honolulu,
HI 96814 Phone: 586-8121 ( V/TDD)
FAX: 586-8129 http:
// www.hawaii.gov/health/dcab |
ATTENTION: ____________________________________ Date:______________________
(DCAB
staff name, only if resubmittal)
Submission stage: o New submission o
Resubmittal (This form is required for all
submittals)
Who is submitting? o Department/Agency o Design Consultant
Items submitted: _______ Drawing prints, specify number of
sheets _________________________
_______ Specifications
_______ Other, please specify ____________________________________________
DCAB# _______________________________ (Refer
to previous review if this is a resubmittal)
Project Name: ________________________________________________________________________
Location: ___________________________________ Island:______________________________
Agency Project #: ___________________________________ TMK:_______________________________
NOTE:
Fill in all information below for both State or County
Department/Agency and Design Firm/Consultant
Contact Person: ________________________________________________________________________
Department/Agency: ________________________________________________________________________
Address, City, State, Zip: ________________________________________________________________________
Phone Number: ___________________ Fax:_____________ e-mail:___________________________
Contact Person: ________________________________________________________________________
Design Firm/Consultant: ________________________________________________________________________
Address, City, State, Zip: ________________________________________________________________________
Phone Number: ___________________ Fax:______________ e-mail:__________________________
Project Phase: _____ Conceptual _____ Prelim _____ Pre-Final
(Check one) _____ Final _____ Construction _____ Post
Construction
Project Type: _____ New _____ Addition _____ Alteration
(Check all that apply) _____ Transition
Plan _____ ABR
Project _____ Leased
Site
_____ Historic
Site _____ Per
Legal Settlement
Comments:
______________________________________________________________________________________
______________________________________________________________________________________
BELOW THIS BOX FOR DISABILITY AND COMMUNICATION ACCESS BOARD USE
ONLY
Date received: _____________________ Review
date:
_____________________
DCAB Staff: _____________________ Island
Code:
_____________________
Department Code: _____________________ Facility
Type Code:
_____________________
Action Taken Code: _____________________ Turnaround
(days):
_____________________
Future Action (Y/N) : _____________________ SSAD
(Y/N):
_____________________
Comments: