ST1002-CS120720 (2) TEXAS DEPARTMENT OF LICENSING AND REGULATION
COMPLIANCE DIVISION -ARCHITECTURAL BARRIERS
�' ✓ P.O.Box 12157 •Austin,Texas 78711 • (512)539-5669• (877)278-0999 • FAX(512)539-5690
architectural.barriers a Iicense.state.tx.us • www.Iicense.state.tx.us
REQUEST FOR INSPECTION
In accordance with the Texas Architectural Barriers Act, Texas Government Code, Chapter 469.105, and
Administrative Rule 68.52, the owner of a building or facility subject to Chapter 469.101 of the Act shall obtain an
inspection from the department, a registered accessibility specialist, or a contract provider not later than the first
anniversary of the completion of construction.
The request for an inspection must be made by completing this form and submitting it to the authorized party not later
than 30 calendar days after the completion of construction.
The completed Request for Inspection form must be received prior to proceeding with the inspection. Following the
inspection,the owner will be advised in writing of the results.
PROJECT INFORMATION PLEASE PRINT OR TYPE
1.Project Name: 2.EABPRJ#:
OLD7OUJN t OFp LL IM 2, 000007
3.Project Address: Suite#:
i TI-tEL RD 13ETWEEfI LOPPCI-L IUD 4 5 .Co PF U c
City:C,6 PPE L L County:
I2 LL_ I}5 Zip:
-75oi9
OWNER/AGENT INFORMATION (Check One)
I am 0:j the Owner(the person/entity that holds title to the property) or f1 the Owner's Designated Agent
"If you are not the owner,a completed Owner Agent Designation Form must accompany this form.
4. Name: 5.Company/Agency:
<e./i H P.M h VI ti� P1L . C I7y C F CoPP&LL
6. Address: Suite#:
255- Kgt<wP C Lv
City: State: Zip:
C®p pea, Tx -750tcf
7. Phone: 8. Fax: 9. "Email:
972.-3014 - 3(QCg -304-- 7d KrnarV 1 ixt(i-X-g6V
(
10. Signature of Owner/Designated Agent Date
I have authorized the following to perform the inspection(Check One)
NI TEXAS DEPARTMENT OF LICENSING AND REGULATION
If TDLR is authorized to perform the inspection, the Request for Inspection form must be submitted to TDLR and
accompanied by the inspection fee identified in Rule 68.80. All fees received by TDLR are non-refundable.
❑ REGISTERED ACCESSIBILITY SPECIALIST
If a RAS is authorized to perform the inspection, the Request for Inspection form must be submitted directly to the
RAS identified below. Forms and inspection fees received by TDLR will not be forwarded or refunded.
RAS Name: RAS#
Address: City: State: Zip:
Phone: Fax: Email:
TDLR FORM 041 AB 06-10 NOTE: An individual who completes and files this form with the Texas Department of Licensing and Regulation(the Dept.)is
entitled to the following:
1) to be informed about the information that the Dept.collects about the individual,upon their request and subject to a
few exceptions,
2) to receive and review the information,under Sections 552.021 and 552.023 of the Texas Govt.Code,and
3) have the Dept.correct information about the individual that is incorrect,under Section 559.004 of the Texas
Govt.Code.
The Department will add your address to the Architectural Barriers email notification list,which automatically provides Department information on matters affecting Architectural
Barriers.Your email address is confidential pursuant to the Texas Public Information Act;the Department will not share it with the public.For additional information link to:
httpl/www license.state.tx.us/newsletters/TDLR notificationLists.asp