Form Wpi 1 – Fill Out and Use This PDF

TEXAS DEPARTMENT OF INSURANCE

Windstorm Inspections / MC 103-1E 333 Guadalupe Street P.O. Box 149104 Austin, Texas 78714-9104 (512) 322-2203 or toll free 1-(800)248-6032 Fax (512) 322-2273 TDI website: www.tdi.state.tx.us

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 _______________________

ο Inside City Limits	ο Outside City Limits
Structure is located in:	ο Inland II	ο Inland I	ο Seaward
Is the structure located in a Coastal Barrier Resource Zone (COBRA): ο Yes				ο 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:
ο	Commercial		Entire Building (Type): ___________________________
ο	Residential Dwelling			Entire Re-Roof (Type): ___________________________
ο	Duplex				Re-decking
ο Garage Attached by Breezeway			Partial Re-roof (Type and Area):____________________
ο	Detached Garage				Re-decking
ο	Condominium (# of Units:______*)			Alteration (Type): _______________________________
ο	Townhouse	(# of Units:______*)		Repair (Type): __________________________________
ο	Apartments	(# of Units:______*)		Mechanical Only (Type):__________________________
		* Per Building		Foundation Only (Type):__________________________
ο	Farm & Ranch			Addition (Type): ________________________________
ο	Metal Building		Retrofit of All Exterior Openings:___________________
ο	Other (Specify):__________________			(For windborne debris protection only (impact resistant
				exterior opening products or shutters). All exterior openings
				shall include windows, doors, garage doors, and skylights.

Comments:

______________________________________________________________________________________________________________________

______________________________________________________________________________________________________________________

Submitter Information:
SUBMITTER NAME (please print):________________________________________	DATE: ______________________
TELEPHONE NUMBER: ________________________________________________
PLEASE CHECK ONE: ο Owner ο Builder/Contractor ο Insurance Agent ο Engineer	ο 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
Effective January 1, 2005	1 of 2