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Rev 12/10/09 County of Hawaii DEPARTMENT OF PUBLIC WORKS ENGINEERING DIVISION 75-5706 Kuakini Hwy, Aupuni Center Kailua-Kona,HI 96740 101 Pauahi St.Suite 7 Hilo,HI 96720 CURB RAMP REQUEST FORM This form is to be filled out by or on behalf of a person with a disability who requires the installation of new curb ramps or modifications to existing curb ramps and/or the modification of existing accessible path(s)leading to the curb ramps within the County road right-of-way. Fill out this form as completely as possible or call 961-8327 (voice) for assistance. Provide a written description and/or indicate on the sketch shown below describing the location(s)where curb ramps and/or modifications are needed. Within two(2)weeks of receiving this request, a representative from the Department of Public Works, Engineering Division will be contacting the requestor to validate the request and/or confirm the information that has been provided and/or to schedule an onsite meeting with the requestor to validate/confirm the request. The requester will then be notified whether his request has been accepted or rejected for construction. Date: Name of Person Requesting Curb Ramp(s)/Modification(s): Contact Person(if different from above): Address/Tax Map Key Address/Tax Map Key Phone: Address: City: Zip: Street Name Location of your request and/or use sketch to the right. Street Names: Address/Tax Map Key Address/Tax Map Key Tax Map Key: Address(es): Please mark location of z curb ramp(s)with an"X" Describe the curb ramp work you are requesting. Provide a brief statement of why you are making this request. This information may be used to prioritize requests. Return to: Engineering Division or Fax to: (808)961-8933 Department of Public Works 101 Pauahi St.,Ste.7 Hilo, HI 96720 0 ACCEPTED Date Received: 0 REJECTED BY: REQUEST NO.: County of Hawaii is an Equal Opportunity Provider and Employer