Rolling Oaks MC-CS091114- TEXAS DEPARTMENT OF LICENSING AND REGULATION
_ P. O. Box 12157, Austin, Texas 78711
~~' `~~~~~ (512) 463-3211 • (800) 803-9202 • FAX (512) 475-2886
~l r_%~~r ';~;~ architectural.barriers@license.state.tx.us • www.license.state.tx.us
..
ARCHITECTURAL BARRIERS -INSPECTION RESPONSE FORM
Building or facility owners or the owners' designated agent may use this form to indicate the status of outstanding violations
associated with the referenced construction project that were identified during the inspection performed by a Registered
Accessibility Specialist (RAS) or TDLR Investigator to verify compliance with the Texas Accessibility Standards (TAS).
This form must be submitted to the RAS or TDLR representative noted in Step 4
STEP 1 -PROJECT INFORMATION
PRINT OR TYPE
Name:
~r~fiv~..®/V~' ~~.~N/~~W~+'e`/I~'f~'~:, c._.r,Grwri..,:.~_, EABPRJ #:
O'Yvy~°J~'y~,.`~i.~+~a
Address: Suite No: City: Zip;
STEP 2 -INSPECTION STATUS INFORMATION
All violations cited on the inspection report relating to the above referenced project
A• nave been corrected.
All violations cited on the inspection report relating to the above referenced project
will be corrected by: (completion date).
B.^
Note: Projects inspected by a RAS, have 270 calendar days from the date of the inspection
report to correct inspection violations.
Com letion dates after 270 calendar da s of the ins ection re ort must be a roved b TDLR.
The following violations cited on the inspection report relating to the above referenced project
C ^ will not be corrected:
TAS violation reference(s)
A Variance Application has been submitted and/or approved for:
STEP 3 - OWNER I AGENT INFORMATION
Owner/Agent Narne: Company/Firm:
Address:_ City: State: Zip:
Phoneys#:
~~ ~ L ' 3` ''f/ aL Y~a~.f ,! L' FJ~ax #:
{`/ ~~ ~r ~~i'~ai'!~ .A ~j.~4 p t'.~ "'p~Email: l ~,^~ p _
~f ~ `~C~jI~ ~itif ~~ ~ .. L~-a,."~~' I~ ~y s 1~.~ , ~'~.e~'J
f am the owner of this buildinglfacility or the agent designated by the owner to act on their behalf (check one):
^Owner (Person or entity that holds title to this property) [~ Owner's Designated Agent
I certify by my signature below that the information provided is true and accurate. I also understand that failure to
correct the violation(s) may result in this project being forwarded to the Enforcement Division of TDLR for action.
Signature:
Date: `~ ~~ f
~---
STEP 4 -SUBMITTAL INFORMATION:
FOR RAS ANDlOR TDLR USE ONLY
Name:~~.~r~t,T,~i~,• ~~ ~d~. ~: ~.~,-~
6 RAS # ~~,,, i~J
ita iicable CompanylAgency -~- ., ;,
e~'3~i'4°~pLi~'1~6,d x-~1..-e, .-
Address~g°~ ~/'}y'~y_ryA f JCityq~:p ~q ~ ,+ StJ~a't+e: Zip:Ay~~ g/~
Phone: Fax: ""Email:
I ULK NtS ULy US-U / NOTE An indrv~dual who completes and files (his loan with the Texas Department of Licensing and Regulation (the Dept) is entitled fo the /ollow~ng
~) fn be rnlormetl about the rnlormahon that the Depl collects about the individual, upon their request and subject /o a lew exceptions,
2) fo receive and review the rnformafron, under Sections 551 027 and 552 023 0/the Texas Govf Code and
31 have the Dept c rect rnlormahon about the individual that is rnconecf under Sechnn ,559 OOd o/ the Texas Govt Code.
"The Department will adtl your address fo the Archrfecfural Barriers emal notification list which automaheall y pro vrdes Cepartmen( rnlormahon on matters affecting Archilecfural Barrens Your email address r5 confidential pursuant to the
Texas Inlormatron Acf, the Department will not Shane it with the public For additional rnlormetion Irnk fo hh°/hvww license slate fx us/newslefttersiTDL Rno(rficetion Lists aso