Full Text
Page 1 of 2 CITY AND COUNTY OF BROOMFIELD Engineering Division [PHONE REDACTED] One DesCombes Drive, Broomfield, CO 80020 PUBLIC PRIVATE IMPROVEMENT PERMIT Fax: [PHONE REDACTED] Date: Estimated Construction Cost: Permit Number: OWNER INFORMATION (Primary Party): Owner Name: Owner Business Name: Owner Address: Owner Phone Number: Cell Phone: E-mail: CONTRACTOR INFORMATION (Secondary Party): Contractor Name: Contractor Business Name: Contractor Address: Contractor Phone Number: Cell Phone: E-mail: Contractor License PROPOSED CONSTRUCTION OR WORK ACTIVITY: Location/Site Address: Description of Work: Temporary Construction Equipment to be located in ROW: PROPOSED WORK DATES: From: To: Permit Expiration Date: Office Use Only PROJECT ENGINEER/INSPECTOR – CALL ENGINEERING INSPECTOR BEFORE ANY WORK BEGINS: Project Engineer: Inspector: PERMIT APPROVAL CONDITIONS (Office Use Only): X All work must be done per approved engineering plans and Broomfield Standards and Specifications. □ Preconstruction Meeting is required before work may start. Call (303) 438-6378 X Contractor shall provide certification in accordance with Ord. No. 1698: Oil and Gas Wells Production Site Abandonment. □ Sidewalk removal area needs to be cold patched if concrete is not immediate. X No work shall proceed beyond the end date specified on the job site at all times. □ CDOT Approval required prior to commencement of work. X The Public/Private Improvement Permit must be on the job site at all times. □ Bore only. Do not cut street pavement. X All disturbed areas including landscape must be restored to original or better conditions within two weeks of job completion (weather permitting). □ Bike path/sidewalk cannot be closed during construction. X All exploratory potholing excavations shall be repaired per Broomfield Standards and Specifications □ Maintain 10’ horizontal separation from existing utilities and 18” at all crossings. X All traffic control must be in place before work begins. □ Use #57 or #67 (3/4” – 1 fractured rock or flow-fill. 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: X All trenches shall be Patched. □ Other: X Flow-fill required. Mix design must be approved prior to use. □ Other: X Infra-red heat treatment of patch required. ---PAGE BREAK--- Page 2 of 2 CITY AND COUNTY OF BROOMFIELD Engineering Division [PHONE REDACTED] One DesCombes Drive, Broomfield, CO 80020 PUBLIC PRIVATE IMPROVEMENT PERMIT Fax: [PHONE REDACTED] PERMIT QUANTITIES AND FEES: Sanitary Sewer Unit Fee Quantity Fee Concrete Unit Fee Quantity Fee Pipe: $0.35/L.F $ Sidewalks/Trails: $0.25/L.F. $ Pipe w/underdrain: $0.35/L.F $ Cross Pans: $0.25/L.F. $ Manholes: $40.00/EA $ Drive Cuts: $0.25/L.F. $ Services: $12.00/EA $ Curb/Gutter: $0.25/L.F. $ Water Mains Street Surface Pipe: $0.35/L.F $ Asphalt: $0.16/S.Y. $ Valves: $5.00/EA $ Concrete: $0.16/S.Y. $ Fire Hydrants: $15.00/EA $ Base Prep: $0.16/S.Y. $ Blow Offs: $5.00/EA $ Edge Drains: $0.10/L.F. $ Services: $12.00/EA $ Parks/Open Space Storm Drainage Parks/Open Space $0.03/S.Y. $ Pipe: $0.35/L.F $ Landscape/Irr $0.03/S.Y. $ Inlet Structures: $40.00/EA $ Earth Channels: $0.19/L.F. $ Detention Ponds: $0.08/S.Y. $ Fee Calculations: Manholes: $40.00/EA $ No Fee: Inspection Total Fee ($30 min): $ Plan Review Fee (50% of Insp., $20 min) $ Street Cut Fee: $ Other Fee: $ TOTAL FEE: $ 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: □ City Engineer Approval: (Office Use Only) Date: The Owner 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 Owner/Contractor 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. Owner/Contractor Signature: Date: Revised: 12/11/12