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PROPERTY INFO Property Address Date Lot Block Subdivision BILLING INFO Owner Contact Person Phone # Billing Address Alt Phone # City, State, Zip Fax # SERVICE INFORMATION Water Meter Size Wastewater (Sanitary Sewer) Service Size ( 5/8 3/4 1 1-1/2 2 3 4 6 8 ) ( 4 6 7 8 ) RESIDENTIAL NON-RESIDENTIAL IRRIGATION (please complete all applicable) (please choose one) Number of dwelling units Office (square feet) Irrigation (acre-feet / year) Industrial (square feet) Irrigation (gallons / year) Number of dwelling units Number of People Irrigation (area - square feet) Historic Use (gallons / year) Irrigation (area - acres) TERMS AND CONDITIONS * By signing below, you agree to comply with all applicable sections of the City of Lafayette Municipal Code of Ordinances. Applicant Date (total for structure) (this tap) CITY COPY * The City will provide and set the water meter. All other construction and installation will be the responsibility of the applicant or builder. Questions regarding service and meter pit requirements or construction should be directed to the Public Works Department at (303) 665-5588. * All fees are subject to revision upon the Public Works Department survey of the structure or after review of actual water use. These tap fees are in addition to any special payment which may be applicable. * The City of Lafayette will begin billing for water and wastewater service at the current rate when this tap is put to use or 180 days from the date the tap is issued and paid for, whichever occurs first. * This form does not constitute permission to connect for utility service. Permission to tap the main utility lines of the City of Lafayette will be granted in accordance with ordinances of the City of Lafayette only after receipt of a Utility Service Permit signed by a City representative. A Right-Of-Way Encroachment Permit will be required for any work in the City right-of-way. * Meter pit inspection by a City of Lafayette Inspector must be completed prior to the City setting a meter. Please call the Utility Clerk at (303) 665-5588 x3316 to schedule a time for inspection. After inspection, please allow a minimum of 72-hours for the meter to be set. * Any non-metered water connections are punishable with a fine up to $1,000 per day (City Ordinance Section 120-62(e)). Service not valid until Utility Service Permit is receipted and signed by an authorized agent of the City of Lafayette. By signing, I agree that I have read the terms and conditions listed above and agree to comply: