ay

Re-decking

Partial Re-roof (Type and Area): _

Re-deckin g

Print

PC350 (WPI-1) | 0908

APPLICATION FOR CERTIFICATE OF COMPLIANCE Form WPI-1

Physical Address of Structure to Be Inspected (Complete 9-1-1 Street address including house/building number): _______________________________________________________________________ Tract or Addition

_______________________________________________________________________ Lot Tract

_______________________________________________________________________ Block

City Zip Code County

Inside City Limits Outside City Limits

Structure is located in: Inland II Inland I Seaward Is the structure located in a Coastal Barrier Resource Zone (CBRA): Yes No Owner:

Name: ______________________________________ Telephone No.: ___________________ Fax No.: ____________

Mailing Address: ______________________________City: ____________________________ Zip Code: ___________

Builder/Contractor (at time of construction): Name: ______________________________________ Telephone No.: ___________________ Fax No.: ____________

Mailing Address: ______________________________City: ____________________________ Zip Code: ___________

Engineer: Name: ______________________________________ Telephone No.: ___________________ Fax No.: ____________

Mailing Address: ______________________________City: ____________________________ Zip Code: ___________

E-Mail Address:_______________________________ Texas Registration No.: ________________________________

Commencement of Construction (date): Date of Application:

1. Type of Building: 2. Type of Inspection: Commercial

Residential Dwelling

Duplex

Garage Attached by Breezew

Detached Garage

Condominium (# of Units:______*) Townhouse (# of Units:______*) Apartments (# of Units:______*)

* Per Building Farm & Ranch

Metal Building

Other (Specify):__________________

Comments:

Entire Building (Type): ____________________________

Entire Re-Roof (Type): ____________________________

___________________

Alteration (Type): ________________________________

Repair (Type): __________________________________

Mechanical Only (Type): __________________________

Foundation Only (Type):___________________________

Addition (Type): _________________________________

Retrofit of All Exterior Openings: ____________________

(For windborne debris protection only (impact resistant exterior opening products or shutters). All exterior openings shall include windows, doors, garage doors, and skylights.

Submitter Information: SUBMITTER NAME (please print):________________________________________ DATE:_______________________

TELEPHONE NUMBER: ________________________________________________

PLEASE CHECK ONE: Owner Builder/Contractor Insurance Agent Engineer Other (Specify) _______________

FOR TEXAS DEPARTMENT OF INSURANCE INSPECTIONS: MAIL OR FAX TO YOUR LOCAL FIELD OFFICE FOR INSPECTIONS BY ENGINEERS: MAIL OR FAX TO AUSTIN OFFICE: (512) 490-1051

Texas Department of Insurance | www.tdi.texas.gov 1/2

___________________

__________________

http:www.tdi.texas.gov

PC350 (WPI-1) | 0908

NOTICE ABOUT CERTAIN INFORMATION LAWS AND PRACTICES With few exceptions, you are entitled to be informed about the information that the Texas Department of Insurance (TDI) colle cts about you. Under sections 552.021 and 552.023 of the Texas Government Code, you have a right to review or receive copies of information about yourself, including private information. However, TDI may withhold information for reasons other than to protect your right to privacy. Under sec tion 559.004 of the Texas Government Code, you are entitled to request that TDI correct information that TDI has about you that is incorrect. For more information about the procedure and costs for obtaining information from TDI or about the procedure for correcting information kept by TDI, ple ase contact the Agency Counsel Section of TDIs General Counsel Division at (512) 676-6551 or visit the Corrections Procedure section of TDIs website at www.tdi.texas.gov.

Texas Department of Insurance | www.tdi.texas.gov 2/2

http:www.tdi.texas.govhttp:www.tdi.texas.gov

Print: Physical Address of Structure1: Physical Address of Structure2: Physical Address of Structure3: Tract or Addition: Lot: Tract: Block: City: Zip Code: County: Inside City Limits: Outside City Limits: Inland II: Inland I: Seaward: COBRA Yes: COBRA No: Owner Name: Telephone No: Fax No: Mailing Address: City_2: Zip Code_2: Builder Name: Telephone No_2: Fax No_2: Mailing Address_2: City_3: Zip Code_3: Engineer Name: Telephone No_3: Fax No_3: Mailing Address_3: City_4: Zip Code_4: E-Mail Address: Texas Registration No: Commencement of Construction date: Date of Application: Commercial Checkbox: Residential Dwelling Checkbox: Duplex Checkbox: Garage Attached checkbox: Detached Checkbox: Condominium Checkbox: Condominium Units: Townhouse Checkbox: Townhouse Units: Apartments checkbox: Apartment Units: Farm and Ranch Checkbox: Metal Building Checkbox: Other Checkbox: Building Other Specify: Entire Building Checkbox: Entire Building: Entire Re-Roof Checkbox: Re-decking Checkbox: Partial Re-roof checkbox: Partial Re-decking Checkbox: Alteration Checkbox: Alteration Type: Repair Checkbox: Repair Type: Mechanical only checkbox: Mechanical Only Type: Foundation checkbox: Foundation Only Type: Addition Checkbox: Addition Type: Retrofit Checkbox: Retrofit of All Exterior Openings: Comments 1: Comments 2: Submitter Name: Date submitted: Submitter Telephone number: Owner: Builder or Contractor: Insurance Aget: Engineer: Other (specify): Other Specify: Entire Re-Roof: Entire Re-decking: Partial Re-Roof: Partial Re-decking: