ST0301C-CS150724l �Q,B
5 I TEXAS DEPARTMENT OF LICENSING AND REGULATION
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F ` i C-0 Compliance Divislorn/Architectural Barriers Program
P. O. Box 12157 o Austin, Texas 78711 • (512) 539-5669 • (877)278-0999
Fax: (512) 539-5690 • Efnail: techinfo.ab@tdlntexas.gov • Web site: www.tdir.te-Yas.gov
REQUEST FOR INSPECTION
In accordance with Texas Government Code, Chapter 469.105, and TDLR Administrative Rule 68.52, the
owner of a building or facility subject to compliance with Chapter 469.101 shall obtain an inspection to
verify compliance with the Texas Accessibility Standards (TAS) 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 a Registered
Accessibility Specialist (RAS) 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 #:
Bethel Rd & Coppell Rd Paving/Drainage
B4821320
3. Project Address:
Suite #:
Bethel (Coppell to Benton)
Coppell Rd (Bethel to Coop
City:
County:
Zip:
Coppell
Tarrant
75019
OWNER / AGENT INFORMATION (Check One)
® I am the Owner (the person/entity that holds title to the property)
❑ I am the Owner's Designated Agent **
**If you are not the owner, a completed Owner Agent Designation Form must accompany this form.
r)
4. Name:
George Marshall
5. Company/ Agency:
City of Coppell
6. Address:
265 Parkway Boulevard
Suite #:
City:
Coppell
State:
Texas
Zip:
75019
7. Phone:
8. Fax:
9. ""Email:
10. Signature of Owner/Designated Agent Date
I have authorized the following Registered Accessibility Specialist (RAS) to perform the inspection:
RAS Name:
RAS #
Sharon Krueger
428
Address:
City:
State:
Zip:
6405 Tranquility Ct.
Arlin ton
Texas
76016
Phone: TFax:
Email:
817.781.3044
817.457.3038
skrueger@kpluskassociates.com
TDLR FORM 041 AB 02-14 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