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UCLA Procedure 890.0 : Attachment A

Gender Inclusive Facility Waiver Form - Renovations and Additions

GENDER INCLUSIVE FACILITY WAIVER REQUEST BASED ON HARDSHIP

 

Project Number/Description

 

 

Date

 

PROJECT COST

Construction cost of overall project

 

$

 

Construction cost of inclusive restroom work

$

 

Percentage of restroom cost/overall project construction cost

 

 

 

 

 

 

 

 

OCCUPANT LOAD & FIXTURE COUNTS

 

 

Occupant load of building

 

Occupants

 

 

 

MEN

WOMEN

 

Toilets & Urinals

Lavatories

Toilets

Lavatories

1,2,4 Required number  of gender specific toilet/urinal fixtures

 

 

 

 

Existing number  of gender specific toilet/urinal fixtures

 

 

 

 

Number of gender specific fixtures  including new inclusive restroom(s)

 

 

 

 

Deficit (if any) with new inclusive restrooms and fixtures

 

 

 

 

PROXIMITY

 

 

 

Are there other inclusive restrooms in this building? (Circle one)

YES or NO

 

If YES, indicate distance to nearest inclusive restroom in building.

 

Travel distance in feet

 

Travel distance - number of floors

3 If NO, indicate location of nearest inclusive restroom.

 

Travel distance in feet between building entries

 

Pedestrian travel time between building entries

HARDSHIP

(Describe)

 

 

 

If space will be reassigned from programmatic or other dedicated use to construct the inclusive restroom(s), describe secondary effects of constructing restroom in this location.

 

 

 

 

 

 

 

 

INTENT

(Describe)

 

 

 

If inclusive restroom cannot be provided in this location, describe the proposed alternate solution and how it meets the spirit and intent of the inclusive restrooms guidelines.

 

Notes

1  "Separate" refers to California Code of Regulations, Title 24, Part 6--California Plumbing Codes, Section 422.2, Separate Facilities:  "Separate toilet facilities shall be provided for each sex."  See also Table 422.1 of the plumbing code for fixture count requirements.

2  Include additional code-triggered required separate fixture that must be added by the work of the new project, if any.

Pedestrian travel time is encouraged to be less than 2 minutes between building entrances to avoid extending break times
and provide equivalent facilities.

4  Modify form as needed if assessing changing rooms or showers.