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Print Form
CITY OF COPPELL
PAYMENT AUTHORIZATION MEMO
Vendor#: 268
Date: 5/4/2010
Pay to: Texas Department of Licensing and Regulation(TDLR)
(Do not use initials/acronyms/abbreviations)
Address: P.O.Box 12157
Austin,TX 78711
Charge To: Bethel Road II(Phase I)ST 03-01 A
(Fund-Dept-Division-Expense Code)
ACCOUNTING USE ONLY
Amount: $775.00
Description/Explanation $775 for TDLR Project Filing Fee,includes Registration, Approved for payment by:
Fee, Date Paid
Plan Review&Inspection-Pee-
Check Number
Approval
y Invoice No.
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TEXAS DEPARTMENT OF LICENSING AND REGULATION
COMPLIANCE DIVISION - ARCHITECTURAL BARRIERS
P.O. Box 12157•Austin,Texas 78711 • (51 2)539-5669• (877)278-0999 • FAX(512)539-5690
architectural.barriers @license.state.tx.us • www.license.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#:
BET I 5 /Pliasc A (post-project iitsp) B 0000 ci22-
3.Project Address: Suite#:
too tes 30a IL1 ettie. 1 i.
City: County: Zip:
COP?ELL DAL LA 5 75019
OWNER/AGENT INFORMATION (Check One)
I am ❑the Owner(the person/entity that holds title to the property) or 11<ie 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:
Keith 12. InAtevi p.E. _ C°i*v of C ppejf
6. Address: ' Suite#:
255 R9V-K14)A-y �L V'D•
City: State: Zip:
COPPELL 1 I)( 7501 9
7. Phone: 8. Fax: 9. **Email:
972-3o4-36R/ °172-3o4-3570 Km4rvin 9ov
•
10. Signature of Owner/Designated Agent Date
I have authorized the following to perform the inspection(Check One)
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
http://www.license.state.tx.us/newsletters/TDLRnotificationLists.asp
F r ,r Via _
MEMORANDUM
FREESE 4.
Z I �s L, 4
•
1701 N Market St.,#500,LB51 • Dallas,Texas 75202 • 214-217-2200 • fax 214-217-2201
TO: Keith Marvin, P.E. / f s
CC: f 0
FROM: B. Caleb Thornhill,P.E.
SUBJECT: Bethel Road II, Phase I—TDLR Registration
DATE: April 22,2010
I've included in this package one(1)set of signed and sealed plans, one(1) set of construction
specifications and one(1) "Architectural Barriers Project Registration Form". Please review the form and
see if you have any questions.
The estimated construction cost related to pedestrian movements is $103,854.08 which includes; 8"& 10"
Reinforced Concrete Stamped Roadway—Crosswalks,4"Reinforced Concrete Sidewalks,Barrier Free
Ramps,Ped Pole Assembly, Pedestrian Signal Sections,Pedestrian Push Button and Sign Assemblies,
and Bridge Sidewalk. The construction costs are from the revised quantities.
You'll need to submit the form, plans and specs along with a TDLR fe- •f$175 to a.,+dress shown atop
the form. The fee is for plan review and TDLR project filing for an e- imated con ction costs $50,000-
$200,00.
There will be an additional fee of$350 for the inspection fee once construction is complet= That will not
be needed at this time.
If you have any questions or concerns, feel free to contact me at 214-217-2282.
K (/,06)
TEXAS DEPARTMENT OF LICENSING AND REGULATION For Department Use Only
P.O. Box 12157,Austin, Texas 78711
,,�;� (512)463-6599•(800) 803-9202 • FAX(512)475-2871
Iti
�'1.,;, 4J : customer.service c( license.state.tx.us • www.license.state.tx.us
IMPORTANT INSTRUCTIONS-PLEASE READ BEFORE BEGINNING
This is only the REGISTRATION of the construction project. The building/facility
owner is responsible for ensuring that the Project Registration Form, construction
documents, and applicable fees are mailed, shipped, or hand delivered to TDLR or a
Registered Accessibility Specialist(RAS)for the required review and inspection of EABPRJ
the project. Please print or type.
ARCHITECTURAL BARRIERS PROJECT REGISTRATION FORM
The required plan review will be performed by: (Check One) IDLR Q RAS(Name/Lic#):
PERSON REGISTERING PROJECT
1.Name n n RAS,, (if applicable)
y,, C►- (►¢v i4 •
2.Address City State Zip
1701 A). /44vte, Sr. / Sol Q .ts 7S2341
3. Phone **Email
( 21q) 2-17. 2282- bef (It Cruse*camel
PROJECT
4. Project Name 6‘57-A51._ /Gn o 1
5. Building or Facility Name
/SS I0*.,o
6.Address City//,� Zip County
/(?U �r0 Soo b.3. &fr,61.- 12044 0..019944. 75a/5 D .40
TENANT(if other than owner)
7. Tenant Contact Name /A Phone
( )
BUILDING OR FACILITY OWNER(person or entity that holds title to property)
8. Name /-+grrof 64. - k r7i <"lti/, (am.) C9703o - 348/
9.Address State Zip
2-S'c- P 4 Y 6c-v Q oRPtt.c. ;7c 7s-o/9
10. Owner Contact Name
7 7i4 044z.1,AJ, P.6_
11. Address City Stat Zip
-
2S wo4y► iSc-vo _ (-0PP w... / 7Sb1,
12. Phone **Email
( r17Z) 3a�I/ .-3 to ti 1 Q,•vN @ e; • (. / IL 47C.c.S
DESIGN FIRM
13. Name Phone 0/C1p.S /NC. (1
) 2l?-22.92
14.Address City State Zip
!'7D/ A). M�x.#Sr Sr, Sh„ s'a! D- �= -ar 7‘202-
15. Designer Nam **Email /�
• 0--s4ft..3 / 1 O Ay)Hi 44- @ -t late -e. L o
16. Type of License: (Check One) ❑Architect [ Engineer License Number(if applicable)
❑ Interior Designer ❑ Landscape Architect ❑Other(includes not licensed) 9282-3
PROJECT DESCRIPTION
17. Start Date(MM/YY): trJ zip ip 18. Completion Date(MM/YY): 211/ 19. Estimated Cost$/o3, &ti_ or
20. Type of Work: (Check One) ['New Construction 121Renovation/Alterations ❑Additions to Existing Building ['Historic Preservation
21. Type of Funds: (Check One) E1ublic Funds, public land, or is a state lease 22. State Lease No.(if applicable)
Privately funded, on private land for private use
23. Does this building(s) have more than one level? (Check One) Q Yes Ef'No
24.Are there any elevators, escalators, or platform lifts in this building? (Check One) Q Yes J No
25. Does this building(s) have any boilers? (Check One) Q Yes I'RIo
26. Scope of Work:C,3m,iaSL-S of 700 Sy of r c.A.n5 , 0,M f, 1 Zoo sr or- si4.i041,4c, /(p 60/44,01. All
R,Ib•+AS. #1112-1412.4.6 04441/1.64 .blvb unwry 0imi 4ovI#4..�n.tc,Mi4 J aegowsr,U. .4 , Sk )4h. R•.c..jcMJ ',
4.5•«D V•h. er er,sr lwL. Amor.
.)LR FORM AB05 10-08 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) to 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:http://www.license.state.tx.us/newsletters/TDLRnotificationLists.asp
INSTRUCTIONS FOR COMPLETING A PROJECT REGISTRATION FORM-AB 005
1. Person Registering Project Name-Enter the name of the person completing the form
2. Address-Enter the mailing address and suite number(if applicable)of the person named in#1
3. Phone-Enter the phone number and email address(optional)of the person named in#1
4. Project Name-Enter the name of the project(examples:CLASSROOM ADDITION,TENANT FINISH OUT FOR DR.SMITH)
5. Building/Facility Name-If this project is located in a building or facility with a name,enter the name(examples:the"CLASSROOM ADDITION"
is located in the building or facility named'WASHINGTON HIGH SCHOOL";the"TENANT FINISH OUT FOR DR.SMITH"is located in the office
building named"MEDICAL PLAZA II")
6. Project Address-Enter the physical address(if available)and the suite number(if applicable)of the project. Post Office Box numbers are not
acceptable.
7. Tenant Contact Name - Enter the name and phone number for the contact person or persons, company, corporation, authority, commission,
board,governmental entity,institution or any other unit that will occupy the project space.
8. Building or Facility Owner- Enter the name and phone number of the person or entity (company, corporation, authority, commission, board,
govemmental entity,institution or any other unit)that holds title to the property.
9. Owner Address-Enter the mailing address and the suite number(if applicable)of the facility owner named in#9.
10. Contact Name-If there is a contact person other than the facility owner(as listed in#9),enter the name and phone number of the person
representing the owner
11. Contact Address-Enter the mailing address and the suite number(if applicable)of the person named in#11 if other than the owner.
12. Contact Phone-Enter the phone number and email address(optional)of the person named in#11 if other than the owner
13. Design Firm-Enter the name and phone number of the design firm or company responsible for the design of the project.
14. Firm Address-Enter the mailing address and the suite number(if applicable)of the firm named in#14.
15. Designer Name-Enter the name of the architect,engineer,interior designer,or landscape architect with overall responsibility for the design of the
project and whose seal is affixed to the drawings and enter their e-mail address.
16. Type of License - Check the box for the applicable license type of the designer and enter the license number (if applicable). If no design
professional,check the box for"other".
17. Start Date-Enter the date construction is scheduled to begin(month and year).
18. Completion Date-Enter the date construction is scheduled to be completed(month and year).
19. Estimated Cost-Enter the estimated cost of construction.Cost should not include site acquisition,furnishings,or equipment that is not part of the
building mechanical systems.
20. Type of Work-Check the box for the applicable type of work.
21. Type of Funds-Check the box for the applicable method of funding.
22. State Lease No.(if applicable)-Enter the state lease number if the construction project is for purposes of a state agency lease contract and/or
occupancy by a state agency.
23. Does this building(s)have more than one level?-Check yes or no
24. Are there any elevators,escalators,or platform lifts in this building?-Check yes or no
25. Does this building(s)have any boilers?-Check yes or no
26. Scope of Work- Enter a detailed description of the construction activities. WHAT TO SUBMIT
1. One complete set of construction documents (plans and
TDLR FEE SCHEDULE specifications)for all disciplines.All documents applicable to the
The following fees are applicable only to services performed by TDLR. project should be submitted as one package.
(Note:If services will be performed by a RAS,please contact the RAS for fee
information as they set and collect their own fees.) 2. A completed Architectural Barriers Project Registration Form or
1_ _ _. _ _ ___ _._._��,�„_.__._ _ __ AB Project Registration Confirmation page for each site/address
Estimated Construction Cost Plan Review Fee TDLR Project Inspection Fee or State Lease Registration Form(if applicable).
1 Filing Fee
- -- --- 3. If the review and/or inspection will be performed by TDLR,
50,000-200.000 $250 $175 $350 a submit a check or money order payable to "Texas Department
- - I of Licensing and Regulation"at P.O. Box 12157, Austin, Texas
1200,001-500,000 f$315 I$175 $375 78711.
500,001-1,000,000 _$380 1$175 $400 _...J 4. When construction documents are submitted after completion of
11,000,001 r -5,000,000 P4 _. .,__._. $445 -�~$175 $aa5 construction,the late submittal Project Filing fee shall apply.
5. An architect, interior designer, landscape architect, or engineer
5,000,001-10,000,000 j$575 $175 $575 with overall responsibility for the design of a building or facility
- i s� subject to §469.101 of the Act, shall mail, ship, or hand-deliver
10,000,001-15,000,000 1$620 $175 $620 the construction documents along with a Proof of Submission
j 15,000,001-25,000,000 7;785 $785 form to the department,a registered accessibility specialist,or a
- - - -- contract provider not later than the fifth day after the plans and
25,000,001-50,000,000 $955 $175 $955 specifications are issued. In computing time under this
_.. subsection,a Saturday,Sunday or legal holiday is not included.
X50,000,001-75,000,000 $1175 $175 $1175
�� 6. In instances when there is not a design professional with overall
>75,000,000 (Contact TDLR $175 'Contact TDLR J responsibility, the owner of a building or facility subject to
1
L Project Filing
Fee M T $300 _ J §469.101 of the Act, shall mail, ship, or hand-deliver
construction documents to the department, a registered
Preliminary Review Fee $145 each I accessibility specialist, or a contract provider prior to filing an
- j application for building construction permit or commencement of
State Lease Inspection(no construction) $225 per lease construction.
7. An Elimination of Architectural Barriers Project Registration form
Special Inspection Fee _W _ $215 per hour,one hour minimum ( or Architectural Barriers Project Registration Confirmation Page
Variance Application Fee $175 each 1 must be completed for each subject building or facility and
submitted along with the applicable fees when the design
Variance Appeal Fee 1$200 each -�_,j professional or owner submits the construction documents.(One
complete set of construction documents (plans and
Example:Estimated construction cost is$250,000;submit the project filing fee of$175.00 and specifications) for all disciplines). All documents applicable to
the review fee of$315.00 for a total of$490.00. The inspection fee would be$375.00. the project should be submitted as one package.
NOTE: All fees are non-refundable.