Accessiblity Hardship Form
Page 1 of 2 City of Cypress- Building and Safety Division •Disabled Access Unreasonable Hardship Form
Valuation Threshold Amount: $170,466 Value for Jan. 2020
Application for Unreasonable Hardship Exception to Disabled Access Requirements
Project Address Plan review no.
Owner Telephone ( )
Applicant Telephone ( )
It is requested that the above named project be granted an exception from the requirements of the State of California Title 24 accessibility noted
below.
A. Section 11B-202.4 Exception (8): Applicable to existing buildings where the construction cost at this tenant space over the last three years
does not exceed the valuation threshold amount. The specific accessibility features that create a hardship may be exempted but not all the
accessibility features. The area of alteration itself may not be exempted.
Access Features
Item descriptions below
Does this feature meet the
latest edition of Title 24
If not, is this feature going to be
made accessible as part of this
permit?
Cost of making feature accessible?
(Attach documentation.)
1. Path of travel to entrance $
2. Entrance $
3. An accessible route to the
altered area
$
4. Elevator $
5. Sanitary facilities $
6. Public phones $
7. Drinking fountains $
8 Signs/Other (specify) $
Total cost of access features provided (A) $
Total cost of valuation of this project and all other work performed
over the last 3 years in this tenant space (B*)
$
Percentage of total cost of project: (A/B)x100= %
Description of features to be provided
City of Cypress
Building Safety Division
5275 Orange Ave, Cypress, Ca 90630
buildingpermits@cypressca.org
Page 2 of 2 City of Cypress- Building and Safety Division •Disabled Access Unreasonable Hardship Form
Alterations performed over the last three years in this tenant space (*Include in total valuation B above unless 20% of valuation of individual
remodel has already been expended on access feature (provide documentation)).
Permit Number Date Description Valuation
$
$
B. Specific Exceptions
This part is generally used for remodels exceeding the threshold amount and where Title 24 provides an exemption from specific accessibility features.
Exceptions Requested Code Section/exception Cost of Making Features Accessible
(Attach Documentation)
Description
The cost of all construction contemplated is $
The access feature increases the cost of construction by (% of construction cost)
The impact on financial feasibility of the project, if the requested action is not approved is
The facility is used by the general public for the purpose of
Architect/Designer Owner
Address Address
City State Zip Code City State Zip Code
Signature Date Signature Date
For City Use Only
Date Received Received by
Findings and decisions of the Enforcing official:
o Request Granted
o General Unreasonable Hardship Exception request approved based on CBC Section 11B-202. Access
features listed on the front of this form will be provided as part of thispermit.
o Specific Exception (s) request approval based on Section (s) . All other access
features must be provided as specified.
o Ratification required. This decision must be ratified by the Board of Appeals and Advisors. Application must
be completed and a filing fee paid before the board can hear the request.
o Request denied. If you disagree with this determination, you may seek an appeal through the Board of Appeals
Page 3 of 2 City of Cypress- Building and Safety Division •Disabled Access Unreasonable Hardship Form
and Advisors. An Application must be completed and a filing fee paid before the board can hear the request.
Building Official: Please print Signature of enforcing official Date