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- . COMMUNITY DEVELOPMENT: BUILDING DEPARTMENT 011e Des.Combes Dr • Broomfield, CO 810020 • Office 303.-438.,6370 • Fax [PHONE REDACTED] • buildiniliJ)ermib;(!lbroomfield.org NEW ONE & TWO FAMILY DWELLING PERMIT APPLICATION Date Received Permit Number Address of Proposed Construction Subdivision Lot Block I Property Owner Owner Phone Number Owner's Address (if different from above) City, State, Zip Contractor Contractor Phone Number Contractor License Number Contractor Address City, State, Zip Job Contact Name Contact Office Phone Number Contact Mobile Phone Number Job Contact EMail Address Job Contact Title Model / Plan Number: Elevation: New Model: Project Valuation (Including total value of work, materials, labor, overhead and profit.) BMC §15-03-100 Trade General: Electrical: HVAC: Plumbing: Fire Sprinkler: Subtotal: Lawn Sprinkler: Total: Valuation $ $ $ $ $ $ $ $ Name of Subcontractor Signs, construction trailers, and fences require separate permits Submittal shall include 1"=20' Drainage Plan that shows building setbacks from property line to closest point. Indicate actual distance to property line below: Front Setback: I Left Side Setback: Right Side Setback: Rear Setback: Description of Construction Walkout: Accessible Type: A B C I Building Height: Soil Report Number: By: Foundation Type: Engineer: Basement Floor Type: # of Bedrooms: I # of Bathrooms: IECC Compliance Method (Please check one) Number of Stories: Area of 1st floor: Area of 2nd floor: Area of 3rd level: Area of 4th level: Total Area: # of Fireplaces: I # of A/C Units: Prescriptive Performance Area of finished basement: Area of unfinished basement: Area of garage: I Spaces: Area of uncovered deck: Area of covered deck: Area of patio cover: Area of covered front porch: Affordable Housing Square footage: Fire Sprinkler system Type: P2904 130 It is the owner's responsibility to obtain any Homeowners Association and/or Architectural Control Committee approvals that may be applicable. I hereby state that the above is correct. I recognize that the approval of plans, issuance of a permit, or subsequent inspection approvals shall not be construed to allow violations of the code or other ordinances or laws enforced by the City and County of Broomfield. I consent to provide entry to inspectors as set forth in the building code and to request inspections as required. I consent to pay the use tax based upon the purchase price of all building and construction materials, as required by ordinance. I understand records are subject to audit and verification for 3 years following final inspection or C.O. Broomfield Municipal Code requires taxpayers to maintain building use tax records for 3 years. All materials, drawings or documents submitted for this permit become public record and may be released to the public. By signature below the signatory certifies and declares that he/she is either the Owner or the Authorized Aaent of the owner of the 1Jro1Jertv. Signature: Print Name: Date: I I I I I Office Use Onlv I I I Building Dept. Approval: Plan Review Fee: Date: I I Building Division, Revised October 2024