HomeMy WebLinkAboutC04-242 Crown Mountain Park and Recreation District- --- .--.- ~~ y -? yz -~
Mid 'Ir~lley- Metr®p®litan ®istric~ ~ D
0031 Duroux 1 ~Znc Suite A • B~i~;~lt CO 8~ 62 ~ -Q357
Phone; (97Q) 92.7-477 - >=:zx (970) 9 .?_7-1 ~~ 7
F3usincss Hours: Monday -'T'hursday. 0:00 a..m. - 3:00 p.m.
APPLICATION FOR WA'I'1~R ANn SI;VVF,R SERVICE AND TAI' PF,,RMIT --
COM1vILRCXAx., CIFIURCH, SCROOL
*Plcasc complete and rcturt~ tv Mid Vztllt~y Metropolitan Uistrirt"`
Name of Applicant: ~~row~. ~o~~,/c~n.~,~.. ~d-J"~ ~ ~-E`-~`r~i ~t~~~+.G~ ~q`{ C~`~~~
Address: aae ~lQ Ca~v.-ti.., l7 v~~~~,, Cam„-lo~,..d.~l.e~ Go cc {~,t z3
Phone: (H) (W)~t7o ~lb.~ X030 (Fax} g,?~ '~63 Ga3z.
Service desired: Water ~ Sewer t/
Owner of Properly to be Served: ~a~ l~ C~au~~u
Address: ~~ '[~~~ru •~ So , C= ~1~. Co g ~b~ t'hone:~l70 3y~-~(ooo
Mailing Address for District Bil ings: o].0 6.agl~ Crw..~, Sri ~+ e ~ 5 ~: ~G 1~ Cu~~,~,r„ti tt-t`-,_~
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Legal Description of property to be Served: (Attach photocopy if necessary) 5 ~c~ o~'~u. ~ l,~ Qt~
Street Address of Property to be Scrvcd: o ~ ~ 4~ Ca 17r~ ~' e b
Subdivision or Development: v~ Y3lgck/Lot: ,mod
Structures on Properlry (ifthcrc is more than one structure ofthe same type, give r~^^^~~^
each):
Rcstaura»t, bar, lounge, tavern (specify) - Sea
Banquet rooms: Seats:
Drive Ins: Car Stalls:
LaundromAts -
Washing machines or available hookups:
Manual flush toilets or urinals:
Continuous flow toilets or urinals:
Lavatory, rnop ox latuadry sinks-
Showers, tubs or combinations:
Washing machines, available hookups:
Other water-using fixtures or
appliances (e.g. drinking fountains):
Service stations -
Fuel nozzles:
Bays or racks where cars can be washed:
Corztmercial buildings, i.c. stores,
offices and industirial warehouses (specify) - ~~-ess:w.. 5-tA...~
..
-- -- - - - -
~_
Ivtanual 11us}t [bilcis or uxi,nals: l o ~ • s ~ ~ Esx.
Continuous flow toilets or urinals:
Lavatory. mop or laundry sinks; ~- Gd . ~- E 4R e~ _
Showers, tubs or combinations;
Washing machines, available hookups;
Other waLez-usizag flxtuzes or
appliances (c.g. drink fountains):Drw.~c~..~ Fsw~-~~.>
Procass water From commercial
Establishments -
Number oI'gallons per day:
't`ypes and quantities of wastes invvlvcd: _
i3arberfbeauty shops: Chairs:
`Cltcatcr5; Scats:
Grocery stores -number of square feet:
5. a ~.Q ~
.mil ~p 2
for aA11 co~nnmct•cial classificsitions:
Square feet of irrigated green space: 1t~~r~
Other water uses or appliances (e.g. decorative fountains): ~~,c~.
NOTF,: The number ol` >/QRs required for C.hurehos and Schools must be ealeulAted on an
in<tividual basis by a representative of the Ditrict.
Current Uae of Property: ~T :c,sl{,xr~pP~..` New or Proposed Use: tea--k~~Q~~c~
Number of EQRs Required, per District iL-QR Sclacdule; 5 t ."•4 t . 25 . 5.6 S
Nurnbe~r oFPrepaid EQRs to be applied to this tap:
Owner of Prepaid FQRs:
ddre;ss:
Phone:
NOTE: Attach a copy oi'the document which atisigns the prepaid lap to you. '(Jnless attached, no
credit for the prepaid tap will be granted.
Nutnbcr oFfrcc 1/QRs to be applied to this tap:
Owner oi' free EQRs:
,A,ddress:
Phone:
NOTE: Attach a copy of the document wlticl~ signs the free tap to you. Unless attached, no
credit for the free tap will be graatcd_
I, the applicant named above, as lawf"uI owner ofthe property dCSCr. i bed above yr on bchalFof the
lawful owner, hereby apply to Mid Valley Metropolitan District for ch~s privilege vfwater and/or sewer
service pursuant to §G_03 ol'the Distrlet's Rules and Rcgulativns. I ~crtily that the above description of
,re„
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the property to be served, and the structures and water uses thereon, is accurate. T underctanc3 tlznt l' mutt
laavc the new tap inspected by District representatives And hereby consent to an inspection of the
premises at a rcasonnble time and in a zeasonable ~nnanner I'or the purposes of approving the tap and
verifying the tap fee to be eharSed. I agree to give the District 24 hours notice before such an inspection
is needed, I understand that 5erviCC charge, begin to accrue: from the date of physicAl connection. I
agree to abide by the Ruler and Regulations of the District as so[ by the Board of Directors and amended
from time to time, and to notify the District ofany changes in the structures or water uses described in
Ibis applicatioat.
Applicant Datc ~ ~ ()
%O iLt _ KC ~,G~i ec._... A ~.,,~,
.6aA.eo? .T ~/~``~ ~O~syl ~/K.GZS ~.u.(C _ ~/.e.1~' l' /r.. ~ ~/
OI=FICL- USL- ONLY
Cvp,}F ot'water and sewer policy givcn'1 Rules & lZegulativn:c o1't'ered?
Tap fee Paid
jnitial $ Datc _
Final $ ,Date
Watcrrights dedicated? _
Lipp ~~tsnsiQn fcc prquircd? Paid $
Application approved (becomes a tap permit).
Date ey
Account number assigned [nspection scbedul.ed foX
Comments
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L- QR~
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Received by
Received by
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