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Application for: ia . ' OH DHComb@s. IDr • &roomf1eild, CO 80020 • Offlc@ 303.4.38.63701 • Fax 3'03.438.6207 • co:ntr:actorlh:ens@(i'broomf1eld.0111 COMMUNITY DEVELOPMENT: BUILDING DEPARTMENT • C'ot,oa,SP. ~ I I I I I I I I I I I I Water License Sewer License Irrigation Only Location of Service Subdivision Filing Block Lot Property Owner Owner Phone Number Owner’s Address (if different from above) Billing Address Job Contact Name Job Contact Email Address Contact Phone Number Residential Detached Single Family Dwelling / Duplex 1 TE 1 ERU Attached Single Family Dwelling /Townhome 0.6 TE 1 ERU Apartment/Condo number of units: Number of units x 0.4 = TEs Number of units x 1.0 = ERUs Non-Residential Estimated Water Consumption: gallons per year TEs ERUs Irrigation Estimated Water Consumption: gallons per year Applying for Separate Irrigation Tap TE’s Additional Information Date Taps Paid: Single Family Detached Commercial Water Tap Equivalents: Single Family Attached Industrial Water Meter Size: Mobile Home Public Sewer Size: Apartment/Condo Units: Irrigation Size: Sewer Equivalent Residential Units: Stand-By Fire Size: Existing water license: Yes No Existing TEs Existing ERUs Fire Sprinklers: Yes No Applicant hereby acknowledges and agrees that the use of water or sewer granted under these licenses will be in accordance with all applicable City and County ordinances. I acknowledge that a water or sewer license may not be transferred or sold except in conjunction with the sale or transfer of the underlying property. I further acknowledge that the water license associated with the above mentioned property was issued based upon the estimated maximum water consumption indicated above. I hereby agree to pay additional license fees, tap fees, and meter fees should consumption exceed that amount. I understand that 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. The minimum service charges established by BMC 13-12 shall begin on the date the water and/or sewer license is purchased. Fees are subject to change pursuant to Title 13 of Broomfield Municipal Code. Signature Print Name Date Office Use Only Type of Fee Total Fees Due Fees Paid Water Meter: Water License: Sewer License: Residential Construction Water Fee: Total: The above fees have been paid and are on deposit with the City and County of Broomfield: Date: Building Division, Revised March 2025 Date Building Permit Number Water / Sewer License Re-Use