Form Wpi 1 Ac – Fill Out and Use This PDF

APPLICATION FOR ALTERNATIVE CERTIFICATION

WPI-1-AC

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 _______________________

O	Inside City Limits	O Outside City Limits
Structure is located in: O		Inland II	O Inland I	O Seaward
Is the structure located in a Coastal Barrier Resource Area (COBRA): O Yes					O 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:_____________
	Email Address: ___________________________________Texas Registration No.:______________________________________
Commencement of Construction (date): __________________				Date of Application: __________________________
1.	Type of Building:		2. Type of Inspection:
	O Residential Dwelling		O Entire roof, as defined in 28 TAC §5.4924(1).
			(Type/Brand):_________________________

□Re-decking (select option below)

			□ Entire □ Partial-location:__________________
O	Garage Attached by Breezeway	O	Windborne debris protection for all exterior openings, as
		defined in 28 TAC §5.4924(2). Includes shutter systems and other
		impact-resistant products, except for wood structural panels. Exterior
		openings include exterior doors, windows, garage doors, skylights, and
		other openings.
		(Type/Brand):_________________________
O	Duplex	O Exterior wall coverings for the entire structure, as defined in 28
		TAC §5.4924(3).
		(Type/Brand):_________________________
O	Detached Garage

Comments:

____________________________________________________________________________________________________________________

____________________________________________________________________________________________________________________

Submitter Information:

PLEASE CHECK ONE: O Owner O Builder/Contractor O Insurance Agent O Engineer O 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: 512-322-2273

Form WPI-1-AC
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NOTICE ABOUT CERTAIN INFORMATION LAWS AND PRACTICES

With a few exceptions, you have the right to access information that TDI collects about you. Under Government Code §552.021 and §552.023, 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. Government Code §559.004 entitles you 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, please contact the Agency Counsel Office of TDI's Legal Section at AgencyCounsel@tdi.state.tx.us or you may refer to the Corrections Procedure section on our websites.

Form WPI-1-AC
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