Tdlr Form 041ab - Request For Inspection

TEXAS DEPARTMENT OF LICENSING AND REGULATION

COMPLIANCE DIVISION/ARCHITECTURAL BARRIERS PROGRAM

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P.O. Box 12157

Austin, Texas 78711

(512) 539-5669

(877) 278-0999

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Fax: (512) 539-5690

Email: techinfo.ab@tdlr.texas.gov

Web site:

REQUEST FOR INSPECTION

JKA #

In accordance with the 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#:

3. Project Address:

Suite #:

City:

County:

Zip:

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.

4. Name:

5. Company / Agency:

6. Address:

Suite #:

City:

State:

Zip:

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 #

Jeffery L. Kelley

55

City:

State:

Zip:

Address:

780 N Watters Rd, #150

Allen

TX

75013

Email:

Phone:

Fax:

(972) 422-5384

(972) 422-5654

Fax: (972) 422-5654

or

Email:

TDLR FORM 041AB 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: