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PUBLIC/PRIVATE IMPROVEMENT PERMIT Applicant Information Estimated Construction Cost: Permit Number: (Office Use Only) New: Renew: Warranty: Dry Utilities: Name of Applicant (include contact person) Address: 24 hour emergency phone: Date: Contractor Information 24 hour emergency phone: Company: Phone: Project Manager: License Contractor Address: Proposed Construction or Work Activity Address (include subdivision name:) Description of Work: Temporary Construction Equipment to be located in R.O.W. CALL ENGINEERING INSPECTOR BEFORE ANY WORK BEGINS Inspector: PERMIT APPROVAL CONDITIONS X All work must be done per approved engineering plans and Broomfield Standards and Specifications. Bore only. Do not cut street pavement. X Contractor shall provide certification in accordance with Ord. No. 1698: Oil and Gas Wells Production Site Abandonment. Bikepath/sidewalk cannot be closed during construction X No work shall proceed beyond the end date specified on the permit without approval from the City. Maintain 10' horizontal separation from existing utilities and 18" at all crossings. X The Public/Private Improvement Permit must be on the job site at all times. Street pavement is less than 5 years old. Special requirements apply: X All disturbed areas including landscape must be restored to original or better conditions within two weeks of job completion. (weather permitting) Use #57 or #67 ( 3/4" - 1 1/2") fractured rock or flow-fill. X All exploratory potholing excavations shall be repaired per Broomfield Standards and Specifications. Flow-fill required. Mix design must be approved prior to use. X All traffic control must be in place before work begins. Infra-red heat treatment of patch required. X Traffic Control plan must meet MUTCD Standards. Certificate of Tapability required before tapping main. X All work shall be limited to Mon. - Fri. 7:00 AM to 7:00 PM unless written authorization from City Engineer is obtained. Other: Preconstruction Meeting is required before work may start.Call (303) 438-6378 Other: Sidewalk removal area needs to be cold patched if concrete is not immediate. CDOT approval required prior to commencement of work. ---PAGE BREAK--- PUBLIC/PRIVATE IMPROVEMENT PERMIT PERMIT QUANTITIES AND FEES Sanitary Sewer Unit Fee Quantity Fee Concrete Unit Fee Quantity Fee Pipe: $0.26/L.F. $ Sidewalks: $0.19/L.F. $ Pipe w/underdrain: No Fee/L.F. $ Cross Pans: $0.19/L.F. $ Manholes: $16.00/EA $ Drive Cuts: $0.19/L.F. $ Services: No Fee/EA $ Curb/Gutter: $0.19/L.F. $ Water Mains Unit Fee Street Surface Pipe: $0.26/L.F. $ Asphalt: $0.16/S.Y. $ Valves: $3.20/EA $ Concrete: $0.16/S.Y. $ Fire Hydrants: $3.20/EA $ Base Prep: No Fee/S.Y. $ Blow Offs: $3.20/EA $ Edge Drains: No Fee/L.F. $ Services: No Fee $ Parks Parks $0.03/S.Y. $ Storm Drainage Pipe: $0.26/L.F. $ Inlet Structures: $16.00/EA $ Earth Channels: $0.19/L.F. $ Detention Ponds: $0.08/S.Y. $ Manholes: $16.00/EA $ (Office Use Only) No Fee: Area 80 Acres+: Inspection Total ($15 min): Contract Inspection Fee (area 80 acres Plan Review Fee (50% of Insp., $5min): Street Cut fee: Other fee: Total: The following are attached with this Permit Application for Review Construction Drawings: Drainage Plan: State Highway Utility Permit: Grading Plan: Geotechnical Report: State Highway Access Permit: Traffic Control Plan: Truck Routing Plan: ROW/Easement Dedications: Park Access Permit: Oil/Gas Well Abandon. Cert.: Railroad/Ditch Company Permission: Requested dates to perform the proposed work From: To: Permit Expiration Date: Staff Approval: Approval Date: Traffic Eng. Approval: Approval Date: Date Paid: The Applicant and Contractor agree to be bound by the provisions of this permit, the Broomfield Standards and Specifications, the Manual on Uniform Traffic Control, approved plans, or any other Ordinance, Law, Rule or Regulation, and that this Permit shall be invalid if, during the performance of the work, a violation of any of the above ensued. By signing this Public/Private Improvement Permit, the Applicant accepts full responsibility for damage done to public or private property (this may include, but is not limited to, street pavement, sidewalk, curb and gutter, landscaping, and utilities); and further understands that he/she will be held financially liable for all required repair work. Applicant's Signature: Date: City Engineer's Signature: Date: