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City and County of Broomfield Community Development 1 DesCombes Drive Broomfield, CO 80020 Y'a -0 [PHONE REDACTED] [PHONE REDACTED] FAX NCO;OR O Utility Tap Order Date: Permit No. Location: Subdivision & Filing: Owner/Developer: Address: Phone No.: Cell No.: Contractor: Address: Phone No.: Cell No.: Owner/Developer or Contractor Signature: 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 3in the box next to the type of Tap request) q Commercial: Tap Equivalent: Tap Size: Corp Stop: How Many: Tap Equivalent: Tap Size: Corp Stop: How Many: Tap Equivalent: Tap Size: Corp Stop: How Many: Tap Equivalent: Tap Size: Corp Stop: How Many: Tap Equivalent: Tap Size: Corp Stop: How Many: Tap Equivalent: Tap Size: Corp Stop: How Many: Tap Equivalent: Tap Size: Corp Stop: How Many: Tap Equivalent: Tap Size: Corp Stop: How Many: Tap Equivalent: Tap Size: Corp Stop: How Many: Tap Equivalent: Tap Size: Corp Stop: How Many: Tap Equivalent: Tap Size: Corp Stop: How Many: Tap Equivalent: Tap Size: Corp Stop: How Many: Tap Equivalent: Tap Size: Corp Stop: How Many: Tap Equivalent: Tap Size: Corp Stop: How Many: Tap Equivalent: Tap Size: Corp Stop: How Many: Tap Equivalent: Tap Size: Corp Stop: How Many: q Fireline: LIII Industrial: Irrigation: Potable: Irrigation: Reuse: Multi-Family: Single Family: q Other: Please Explain: Page 1 ---PAGE BREAK--- 4OVti7Y ORe'P r° a City and County of Broomfield Community Development 1 DesCombes Drive Broomfield, CO 80020 3 -0 [PHONE REDACTED] [PHONE REDACTED] FAX '1otoxao° Utility Tap Order SEWER TAPS (Place a check mark 3in the box next to the type of Tap request) q 4" Sewer Tap How Many: q 6" Sewer Tap How Many: q 8" Sewer Tap How Many: STREET CUT? q YES q NO If yes to Street Cut, a Public/Private Improvement Permit for street cut is 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 303-438 -6378 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. q Single 3/4" tap to be done by Public Works Utility Services q Multiple 3/4" taps to be done by Contract q Single/Multiple 1-112" 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: Corp Stop: Fee: Water Taps: Size: Corp Stop: Fee: Water Taps: Size: Corp Stop: Fee: SUBTOTAL WATER TAP FEE: Size: Fee: Size: Fee: SUBTOTAL SEWER TAP FEE: TOTAL FEE: DATE PAID: q (Attach if required) Sewer Taps: Sewer Taps: Page 2 ---PAGE BREAK--- 4Q 1V OF^'p City and County of Broomfield Y I Community Development 1 DesCombes Drive Broomfield, CO 80020 [PHONE REDACTED] [PHONE REDACTED] FAX • °OLORAb°• Utility Tap Information Subdivision: Filing: Submit an approved address plat that shows all locations to be tapped. Please list in numerical sequence by address: ***For Multi-Family Permits please list the Water Tap Size for the Master Address.*** Address Block Tap Size Water Sewer Date Tap Inspection Signature Lot NOTE: IF ADDITIONAL SPACE IS REQUIRED FOR MORE ADDRESSES, PLEASE COPY THIS PAGE Page 3