Owner Agent Designation

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@tdlr.texas.gov

OWNER AGENT DESIGNATION

In accordance with the Texas Department of Licensing and Regulation's (TDLR) Administrative Rule 68.10(10),

individuals designated to act on the owner's behalf must be designated in writing.

JKA #

FORM MUST BE COMPLETED IN FULL

PLEASE PRINT OR TYPE

Project Information

1. Project Name:

2. EABPRJ #:

3. Building or Facility Name:

Suite#:

City:

Zip:

4. Address:

Owner Agent Information

5. Name

6. Company

7. Address

State:

City:

Zip:

8. Phone:

9. Fax:

10. **Email:

Building or Facility Owner Name (Person or Entity That Holds Title to Property)

5. Name

6. Company

7. Address

State:

City:

Zip:

8. Phone:

9. Fax:

10. **Email:

Owner's Designated Agent

If the owner chooses to designate an agent to act on the owner's behalf, per 16 Texas Administrative Code, Chapter 68,

Architectural Barriers Administrative rules 68.10(10), the owner must do so in writing. The Owner Agent Designation Form

must accompany the Project Registration Form and/or Request for Inspection Form if an agent will be designated.

I

designate

as my agent

Owner (Print)

Agent (Print)

In all responsibilities of ensuing compliance with the provisions of the Texas Architectural Barriers Act, Texas Government

Code, Chapter 469.

Owners Signature

Date

TDLR FORM 043AB 08-12

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 Section 552.021 and 552.023 of the Texas Govt Code; and

3) to have the Department 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 information from the Department on matters affecting Architectural Barriers.

Your email address is confidential pursuant to the Texas Public Information Act and the Department will not share it with the public. For additional information link to: