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<br />EXHIBIT C <br /> <br />ENVIRONMENTAL REVIEW FOR <br />HOUSING ACCESSIBILITY MODIFICATION (HAM) PROJECTS <br />BY CENTER FOR INDEPENDENCE OF THE DISABLED <br /> <br />Date: <br /> <br />A. This is to request an Environmental review for a proposed project at the <br />following address: <br /> <br />B. This address is a ( ) Single family home ( ) An apartment _Age of bldg. if <br />known <br /> <br />C. The improvements to be made to this home/apartment are: ( ) interior* ( ) <br />exterior <br /> <br />NOTE TO OCCUPATIONAL THERAPIST: If both interior and exterior <br />improvements are proposed, check both boxes and identify which <br />improvements are exterior. For exterior improvements to be made to a <br />building which is at least 50 years old, please provide a site plan showing <br />the location and extent of the improvements to the building, a work write-up <br />order and/or plans and specifications of the improvements. <br /> <br />*Interior means the inside of a home, or an apartment. Exterior means the <br />outside of a home or a multifamily building. Improvements to be made <br />outside an apartment, but inside a multifamily family building (such as in <br />hallways, lobbies or stairways) are also considered "exterior" for this <br />purpose. <br /> <br />D. The improvements will consist of the installation or construction of: <br /> <br />( ) Grab bars <br />() Wooden banister <br />( ) Medal Handrail <br />( ) Prefabricated ramp <br />() Wooden ramp <br />( ) Door knobs <br />( ) Hinges <br />( ) Bathroom or kitchen faucet <br />( ) Hand-held shower head <br />( ) Door bell <br /> <br />() Emergency alert system <br />( ) Smoke detectors <br />( ) Non-skid surfaces <br />( ) Dead bolts <br />( ) Door bell <br />( ) Window latches <br />( ) Door peepholes <br />( ) Electronic security systems <br />( ) Platform <br />( ) Trapeze <br /> <br />Other (Please identify): <br />From: Center for Independence of the Disabled (CID) <br />Contact person and telephone: <br /> <br />ATTY/AGR/2006.040 <br />081606 <br /> <br />14 <br />