2. To be Completed by Architect
4. Project Name*
6. Project Address*
8. Project City*
9. Project State*
   -- Select One --AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming
10. Project Zip Code*
12. Building Permit Number*
14. This is to certify that:

    Check all that apply

    1. The "path of travel," which includes bathrooms and drinking fountains serving the altered area, conforms with the Americans with Disabilities Act Accessibility Guidelines (ADAAG).
    2. The cost of providing an accessible "path of travel," including bathrooms and drinking fountains serving the altered area, exceeds 20% of the alteration cost
    3. Only the tenant is making the alteration. The "path of travel" outside the tenant area is under the landlord's authority and is not being altered.
16. A - Cost of alterations to the "primary function" areas (in dollars $)*
18. B - 20% of cost of alteration to the "primary function" area = .2 x A (in dollars $)*
20. List elements that will be made accessible up to 20% of the alteration cost of "B"*
    See Excerpts from ADA, Title III as referenced in the Maryland Accessibility Code for the priority of elements that provide the greatest degree of access.
22. Architect Name*
23. Digital Signature*

    1. Signed

    I, as the licensed architect for the project do hereby certify that the alteration/addition complies with the provisions of the Maryland Accessibility Code.
25. Maryland Registration Seal*
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27. 1. Receive an email copy of this form.
28. Email address

    This field is not part of the form submission.

29. Submit

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