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CITY AND COUNTY OF BROOMFIELD Engineering Division [PHONE REDACTED] One DesCombes Drive, Broomfield, CO 80020 SATURDAY/HOLIDAY & AFTER HOURS WORK REQUEST Fax: [PHONE REDACTED] SATURDAY, HOLIDAY OR AFTER HOURS WORK WILL ONLY BE ALLOWED FOR THAT CONSTRUCTION WHICH IS SPECIFICALLY COVERED BY AN APPROVED ENGINEERING PERMIT. WORK HOURS WILL BE FROM 9:00 A.M. TO 6:00 P.M. ONLY ON SATURDAYS AND HOLIDAYS. ALL NOISE AND DUST ABATEMENT REQUIREMENTS OF THE CITY STANDARDS AND SPECIFICATIONS AND ALL APPLICABLE CITY ORDINANCES MUST BE STRICTLY ADHERED TO DURING THE APPROVED WORK PERIOD. ALL WORK SHALL BE IN ACCORDANCE WITH CITY STANDARDS AND SPECIFICATIONS. APPROVAL OF THIS APPLICATION IS SUBJECT TO THE AVAILABILITY OF CITY PERSONNEL. Date: Permit Number: (MUST BE CURRENT) Applicant Name: Applicant Business Name: Applicant Address: Applicant Phone Number: Cell Phone: Fax Number: Applicant E-mail: CONTACT INFORMATION: Primary Contact: Designated Onsite Representative Title/Position Work Phone Number: Cell Phone: E-mail: Secondary Contact: Designated Onsite Representative Title/Position Work Phone Number: Cell Phone: E-mail: Date of Work: Time(s): Location of Work: Scope of Work: Applicant Signature: Date: ***NOTE: THIS FORM MUST BE COMPLETED AND SUBMITTED BY NOON ON THURSDAY IN ORDER TO BE PROCESSED*** CITY REQUIREMENTS (Office Use Only): □ GEOTECHNICAL ENGINEER IS REQUIRED TO BE ONSITE. □PREVIOUSLY APPROVED PROOF ROLL IS REQUIRED. □ SOIL / ASPHALT DENSITY TEST RESULTS TO BE RECEIVED BY THE END OF FIRST WORKING DAY AFTER. □OWNERS REPRESENTATIVE IS REQUIRED TO BE ONSITE. □ CITY INSPECTION IS REQUIRED. □ FORMAL OR INFORMAL HEARING BEFORE THE CITY COUNCIL REQUIRED □ OTHER: APPROVED DISAPPROVED Engineering Inspection Division: Date: City Engineer or Designee: Date: Revised 12/11/12