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Page 1 of 3 Revised: 4/4/23 CITY AND COUNTY OF BROOMFIELD Engineering Division [PHONE REDACTED] One DesCombes Drive, Broomfield, CO 80020 E-MAIL: [EMAIL REDACTED] UTILITY TAP ORDER PERMIT Fax: [PHONE REDACTED] Date: Permit Number: OWNER/CONTRACTOR INFORMATION (Primary Party/Secondary Party): Owner Name: Contractor Name: Owner Business Name: Contractor Business Name: Address: Address: City: State: Zip: City: State: Zip: Home Phone: Cell Phone: Home Phone: Cell Phone: Contact Email: Contact Email: Property Location (Include Subdivision and Filing): WATER TAPS The water license associated with the above mentioned property was issued based upon the estimated maximum water consumption indicated below. I hereby agree to pay additional license fees, tap fees, and meter fees should consumption exceed this amount. I understand the City and County of Broomfield reserves the right to monitor consumption and assess such additional meter, tap, and license fees based upon the rates in effect at the time of the review. (Place a check mark in the box next to the type of Tap request) Commercial: Fireline: Tap Size: How Many: Tap Size: How Many Tap Size: How Many: Tap Size: How Many Industrial: Irrigation Tap Size How Many: Potable: Tap Size: How Many: Tap Size: How Many Tap Size: How Many Multi Family: Tap Size: How Many Tap Size: How Many: Tap Size: How Many: Irrigation Tap Size: How Many: Reuse: Tap Size: How Many Single Family: Tap Size: How Many Tap Size: How Many: Tap Size: How Many Tap Size: How Many: Other: Tap Size: How Many: Tap Size How Many Please Explain: Owner/Contractor Signature: Date: ---PAGE BREAK--- Page 2 of 3 Revised: 4/4/23 CITY AND COUNTY OF BROOMFIELD Engineering Division [PHONE REDACTED] One DesCombes Drive, Broomfield, CO 80020 E-MAIL: [EMAIL REDACTED] UTILITY TAP ORDER PERMIT Fax: [PHONE REDACTED] SEWER TAPS (Place a check mark in the box next to the type of Tap request) 4” Sewer Tap How Many: 6” Sewer Tap How Many: 8” Sewer Tap How Many: STREET CUT? YES NO If yes to Street Cut, a Public/Private Improvement Permit for street cut is required? (Attach if required) PLEASE BRING OR FAX THIS FORM TO THE CITY AND COUNTY OF BROOMFIELD, ENGINEERING DEPARTMENT, ONE DESCOMBES DRIVE, BROOMFIELD, CO 80020, FAX NUMBER [PHONE REDACTED]. ALLOW AT LEAST 5 WORKING DAYS FOR PROCESSING. THE CITY WILL CALL YOU WHEN THE TAP ORDER IS READY. AFTER YOU HAVE BEEN NOTIFIED OF APPROVAL, PLEASE CALL THE CITY AND COUNTY OF BROOMFIELD ENGINEERING INSPECTION DEPARTMENT AT [PHONE REDACTED] AT LEAST 72 HOURS IN ADVANCE TO SCHEDULE A PRE-TAPPING MEETING. This Tap Order is to authorize the actual connection to a City sanitary sewer or water line and DOES NOT include the cost of the license and fees required to receive sewer or water service. UTILITY TAP ORDER PERMIT APPROVAL CONDITIONS ALL taps are to be done at the direction of the Public Works Utility Services Division. NO tap shall be done until all tapping procedures and requirements have been completed - see attached Tapping Procedures and Requirements. The Construction Inspector will schedule a field meeting to confirm that all procedures and requirements have been completed. If any of the procedures, requirements, or conditions are not met the tapping will not be allowed. Single 3/4" or 1” tap to be done by Public Works Utility Services Multiple 3/4" or 1” taps to be done by Contract Single/Multiple 1-1/2" or 2" taps to be done by Public Works Utility Services Larger than 2" taps to be done by Contractor All tap locations must be surveyed in and locations marked with address and lot/block information before tapping is allowed. (City use only) Water Tap Fee includes Corporation (Corp) Stop Certificate of Tapability Approved: Date Approved: Inspector Assigned: Total Number of Taps: Water Taps: Size: Fee: Water Taps: Size: Fee: Water Taps: Size: Fee: SUBTOTAL WATER TAP FEE: Sewer Taps: Size: Fee: Sewer Taps: Size: Fee: SUBTOTAL SEWER TAP FEE: TOTAL FEE: DATE PAID: ---PAGE BREAK--- Page 3 of 3 Revised: 4/4/23 CITY AND COUNTY OF BROOMFIELD Engineering Division [PHONE REDACTED] One DesCombes Drive, Broomfield, CO 80020 E-MAIL: [EMAIL REDACTED] UTILITY TAP ORDER PERMIT Fax: [PHONE REDACTED] Subdivision: Filing: Submit an approved overall Utility Plan and Address Plat that shows all locations to be tapped highlighted. Please list in numerical sequence by address: ***For Multi-Family Permits please list the Water Tap Size for the Master Address.*** Tap Size Address Block Lot Water Sewer NOTE: IF ADDITIONAL SPACE IS REQUIRED FOR MORE ADDRESSES, PLEASE COPY THIS PAGE