ST0001-CS010803 OTOOOi
TEXAS DEPARTMENT OF LICENSING AND REGULATION
PROJECT REGISTRATION FORM
Code Review and Inspections / ARCHITECTURAL BARRIERS
P.O. Box 12157, Austin, Texas 78711 (512) 463-1668 (800) 803-9202 FAX (512)475-2871
Email Address: ArchitecturaI. Barders @ license.state, tx. us Intemet Address: ~w. lic¢~se, stat¢.ccus
PLEASE PRINT OR TYPE PLEASE SEE IMPORTANT INSTRUCTIONS ON REVERSE SIDE BEFORE BEGINNIN(
1. Project Name
Creekview Drive and Freeport ~a~kway
2. Building/Facility Name
Creekview Drive and Freeport Parkway
3'L°cati°n/Addressi;Ro~/al Lane to State Rdlfity Coppell ZipC°d55019 J C°untTDallas
4. Tenant (if other than owner) n/a Telephone Number
5. Mailing Address I City State I Zip Code
I
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6. Contact Name Telephone Number
( )
7. Mailing Address I City State I Zip Code
I
I
8. Building/Facility Owner (NOT tenant) Telephone Number
City of ¢oppe. ll ~972 ~ 304-3679
9.
Mailing
Address
P.O. Box 9478 C~tYcop[~ell StateTexas~1 Zip Code 75019
10. Contact Name Telephone Number
Kenneth M. Griffin. P.E. ¢972 ) 304-3679
11'MailingAddres~.o. Box 9478 I citYcop~ell StateTexas J ZipC°de75019
12. Design Firm Schrickel Rollins and Associates, Inc, Telephone Number 1,817 , 649-3216
13. Mailing Address I City State Zip Code
1161 Corporate Drive West (~200I Arlington Texas 76006
14. Designer Information: E:]Architect I-IEngineer rqlnterior Designer IDLandscape Architect E]Other License No. (If applicable) Date Drawings Sealed
Print Name:
15. Scheduled Construction I 16. Scheduled Construction 17. Estimated Project
Start date (mm/w): 10/01~ Completion Date (MM/YY): 0l /03 Construction Cost $
18. Descnption: Indicate type of work and bdefly descdbe scope.
IINew Construction [:3Renovation/Alteration I-IAdditions/Renovations I-IAddition to Existing Bldg. r'lNew Const£uction/Renovation l']Historic Preservation
Scope of work: The pro~ect consists of the installation of a 12-inch water ]~me.. ~orm ~ra~ ,
sidewalks, ramps and paving alonK Creekview Drive and Freeport Parkway.
19. · This project involves Public Funds, Public Land, Tax Abatement or is a State Lease I 20. State Lease No.
cI This proiect is Privately Funded, on Private Land, for Pdvate USe~ (if applicable) n/a
21. I hereby notify the Texas Department of Licensing and Regulation of the described project and of my intent to perform, or cause to be performed, all
services necessary to design said project in accordance with the provisions of Article 9102, Texas Civil Statutes. I certify that I am the registered design
professional with overall responsibility for the design of the project and whose seal is affixed to the drawing(s).
Signature of Architect, Engineer, Intedor Designer, or Landscape Architect Date Email Address
OR
Signature of ~3uil~ing ~wner or Designated Agent Date E~'ail Address' '
INDEPENDENTIMUNIClPAL CONTRA CT PROVIDER USE ONLY Date construction documents were
ICP/MCP Project Number ICP/MCP Number. Plan Review submitted to the ICP/MCP for Plan Review
ICP/MCP Number: Inspection
certify that the information pertaining to the submission date of the construction documents is true and
correct.
Sic~nature of Independent/Municipal Contract Provider Date
DEPARTMENT USE ONLY Date Submitted to TDLR
AB Number Complaint Number
TDLR FORM AB 005