SW0501-CS051102 (2) TEXAS DEPARTMENT OF LICENSING AND REGULATION
ARCHITECTURAL BARRIERS - PROJECT REGISTRATION FORM
P.O. Box 12157, Austin, Texas 78711 · (512) 463-6599 · (800) 803-9202 · FAX (512) 475-2871
customer.sewica@licanse.stata.tx, us · www.license.state.tx.us
PLEASE SEE IMPORTANT INSTRUCTIONS BEFORE BEGINNING
NOTE: A project submittal is not complete unless an Architectural Barriers Project Registration Form, a complete set of construction
documents, and applicable fees are submitted to TDLR, a Registamd Accessibility Specialist, or a Contract Provider.
Failure to submit any of these items will delay processing.
PRINT OR TYPE
1. Project Name Samuel Boulevard Curb Ramps
2. BulldlnglFaclllty Name Samuel Boulevard Sidewalk and Curb Ramps (Parkway Blvd. to MacArthur Blvd.)
3. Location/Address Samuel Boulevard
4. Tenant (if other than owner)
City Coppell
5. Mailing Address I City
6. Contact Name
7. Mailing Address I City
8. Building/Facility Owner (NOT tenant) City of Coppell
9. Mailing Address P.O. Box 9478
City Coppell
10. Contact Name Suzan Taylor
11, Mailing Addrass P.O. Box 9478
I City Coppell
12. Design Firm City of Coppell (In-House Design)
13. MailingAddrass P.O. Box 9478
City Coppell
Zip Code 75019 I County Dallas
Telephone Number
)
State
Zip Code
Telephone Number
)
State
IZiP Code
Telephone Number
( 972 ) 304-3679
I Zip Code
State Texas 75019
Telephone Number
( 972 ) 304-7019
I Zip Code
State Texas 75019
Telephone Number
( 972 ) 304-3679
Zip Code
State Texas 75019
14. Designer InformaUon:
fqArchitact r-Ilntarior Designer
[]Engineer DLandscape Amhitect
IqOther
Print Name: Keith R. Marvin, P.E.
License No. (if applicable) 89388
Date Construction Documents
Issued:
Schematic Plans
15. Construction Start t 6. Construction Completion 17. Estimated Project Construction Cost
Date (MM/YY): Est. - March 2006 Date (MM/hq'): Est. - July 2006 $ $72,205.00
18. Description: lndicate type of work and bfiefly describe scope, r-INewConstruction ~Renovation/Alteration r'lAdditions/Renovations
DAddition to Existing Bldg. r-INew Construction/Renovation E]Histodc Preservation
Scope of work: The reconstruction of 26 existing curb ramps along the west sidewalk of Samuel Boulevard - the existing ramps are
noncompliunt. The city is eligible for a Community Development Block Grant.
19. [] This project involves Public Funds, or is a State Lease 20. State Lease No.
[] This project is Privately Funded, on Private Land, for Private Use (if app cable)
21.1 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 Texas Government Code, Chapter 469. I
certify that I am the ragistered design professional with overall responsibility for the design of the project and whose seal is affixed to the
construction documents.
Signature of Design Professional Date *Emaii Address
OR
I hereby notify the Texas Department of Licensing and Regulation of my intent to comply with the provisions of Texas Government Code,
Chaote~.~69~_.-.~
....................... .............................
Signature of Building Owner or Designated Agent Date *Email Address
Page 1 of 2
REGISTERED ACCESSIBILITY SPECIALIST USE ONLY Date construction
RAS Contact Information REVIEW STATUS documents ware
submitted to RAS for Plan
I
RAS#:
Ph#:
I APPROVED DISAPPROVED CONDITIONAL Review
Name: APPROVAL
Address:
*E-mail:
I certi~ that the information pertaining to the submission date of the construction documents is
true and correct.
Signature of Registered Accessibilit~ Specialist Date
DEPARTMENT USE ONLY Date Submitted to TDLR
AB Number Complaint Number
Page 2 of 2
iNSTRUCTIONS FOR COMPLETING PROJECT REGISTRATION FORM - AB 005
1. Project Name - Enter the actual name of the project (examples: CLASSROOM ADDITION, PEDIATRIC FLOOR RENOVATION, CARD SHOP,
DR. SMITH'S OFFICE, etc.) If named for a pemon, use the last name only (ex: WASHINGTON HIGH SCHOOL).
2. Buildlng/Facltity Name - If the "Project" is part of another building or facility, enter the name of the building or facility (examples: Project:
CLASSROOM ADDITION, Building/Facility: WASHINGTON HIGH SCHOOL; Project: JONES & SMITH, INC. OFFICE RENOVATION,
Buildlng/Fectllty: AMERICAN OFFICE pLAZA; Project: CARD SHOP, Building/Facility: MAIN STREET MALL; Project: DR. SMITH's OFFICE,
Bullding/Facilfty: MEDICAL OFFICE TOWER). For facilifies named after a person, use only the last name (example: WASHINGTON HIGH
SCHOOL).
3. Location - Enter the physical location, including the slreet address if available and the suite number if applicable. Post Office Box numbers are not
acceptable.
4. Tenant- Enter the name and telephone number of the person or persons, company, corporation, authority, commission, board, governmental entity,
institution or any other unit that intends to occupy project space.
5. Mailing Address - Enter the complete mailing address of the tenant listed in #4.
6. Contact - Enter the name and telephone number of the person roprosenting the tenant (as listed in #4).
7. Mall~g Address - Enter the mailing address of the person named in #6, if different than the address entered in #5.
8. Building/Facility Owner - Enter the name and telephone number of the person or persons, company, corporation, authority, commission, board,
governmental entity, institution or any other unit that holds tJfle to subject building or facility.
9. Mailing Address - Enter the mailing address of the owner named in #8.
10. Conte~t - Enter the name and telephone number of the person representing the owner (as listed in #8) who is to receive all correspondence
pertaining to the project, including post-construction reports.
1t. Mailing Address. Enter the mailing address of Ihs parson named in #t0, if differont than the address entered in #9.
t2. Design Firm. Enter the name and telephone number of Ihe i~rm or company responsible for the design of the project.
13. Mailing Addroes. Enter the mailing address of the ti~rn or company named in #12.
14. Designer Information - Enter the name of the architect, engineer, interior designer, landscape architect, or building designer having overall
responsibility for the design of the project and whose seal is affixed to the drawings. Include type of license and license number, if applicable. The
date the construcfio~ documents were issued must also be entered. NOTE: Issue is defined in Administrative Rule 68.10.
15. Stert Date. Enter the date construction is scheduled to begin (month and yosr) or began.
16. Completion Dafo - Enter the estimated compledon date (month and year) or the date Ihe project was completed. If the estimated completion date
changes, notify TDLR. NOTE: Administrative Rule 68.80 stipulates owner must pay applicable inspection fees and notify TDLR of the point of
contact within 30 days of completion of construction.
17. project Coat. Enter the estimated cost of construction.
18. Project Description - Provide a brief description of the project. Include square footage, floor levels, special features, etc.
t9. Funding - Indicate the method of funding.
20. State Lease Number(if applicable) - Enter the stale lease number if construction project is for purposes of a state agency lease contract and/or
occupancy by a slate agency.
2t. Name and Signature - of either person noted below:
Signature of Design Professional - Signature of registered amhitect, engineer, interior designer, or landscape architect who has overall
resm~sibilitv for the design of the project and whose seal is affixed to the drawings; or
Signa(~ro of Owner/Agent - Signature and title of the owner or owner agent named in #10. In the absence of a registered design professional,
building designer may sign as owner's agent.
WHAT TO SUBMIT
1. One cemolate set of construction documents (plans and specifications that include all disciplines) submitted as one package to ensure inclusion in
the review.
2. A co~noleted and signed Architectural Barriers Project Registration Form for each site/address or State Lease Registration Form if applicable.
3. For TDLR services, submit check or money order payable to "Texas Department of Licensing and Regulation" at P.O. Box 12157, Austin, Texas
78711. NOTE: If inspection fees are not paid w~th review fees, owner must pay applicable inspection fees and notify TDLR of the point of contact
within 30 days of completico of construction (based on date in #16).
4. Whe~ construction documents are submitted after completion of construction, the Late Project Filing Fee shall apply.
5. For Registered Accessibility Specialist (RAS) review and/or inspection services, contact the respective PAS.
TDLR FEE SCHEDULE
*Late ProjectFIIIng Re~ew Fee Inspection Fee
Project Coat ProJect FIIIng Fee Fee
$50,000 - 200,000 $175 $300 $250 $350
$200,001 - 500,000 $175 $300 $315 $375
$500,001 - 1,000,000 $175 $300 $380 $400
$1,000,001 - 5,000,000 $175 $300 $445 $445
$5,000,001 - 10,000,000 $175 $300 $575 $575
$10,000,001 - 15,000,000 $175 $300 $620 $620
$15,000,001 - 25,000,000 $175 $300 $785 $785
$25,000,001 -50,060,000 $175 $300 $955 $955
$50,000,001-75,000,000 $175 $300 $1,175 $1,175
Greaterthan $75,000,001 $175 $300 Contact TDLRfor Negotiated Fee
· NOTE: Tills fee is only for those projects registered after completion of construction and is in lieu of (not in addition to} payment of the Project Filing Fee.
ALL FEES ARE NON-REFUNDABLE