Stub-in Permit

Owner/Agent Name (print):__________________________________________________ Phone: ___________________________________________

Address: ____________________________________ City: _______________________ State: ___________ Zip Code: ________________________

1. Owner hereby applies for a permit to install stub-ins at the locations listed below.2. At each location, Owner will install a tap, a valve at the property line, a meter pit and yoke, and a service line from the tap to 5 feet

past the meter pit.3. Use of water from a stub-in is prohibited. Any unauthorized use of water may result in cancellation of the stub-in permit. If the per-

mit is cancelled, Denver Water may in its discretion disconnect the stub-in at the main at Owner’s expense.

Stub In Location: County: _______________________ Subdivision Name & Filing #: ____________________________ Zip code: _________________

Address to be served

One address per line (not for fire lines)

Block No.

Lot No. Tap Size Sq. Ft. (Lot Size)

No. of Units

(above 1 unit)

Tap Number (Completed by

DW)

The following fees apply per connection: $ 280 for each 2” and smaller taps No. __________ $__________$100 for each 3” and larger taps No. __________ $_________

Total ……………………………… $__________ (Payable to Denver Water)

1. Owner agrees to pay an annual monitoring fee on the anniversary date of the issuance of the Stub-in Permit until the Permit isconverted to a Standard Water Supply License

2. Owner bears sole responsibility for maintenance and repair of all stub-ins listed.*FEES ARE SUBJECT TO CHANGE & PAYMENT IS REQUIRED WITH APPLICATIONOwner/Agent Signature: _____________________________________________________________Date: ______________________

4052 6/15

1600 W 12th Ave. ▪ Denver, CO 80204303-628-6100 ▪ denverwater.org

Outside Denver locations: The stub-in locations listed here are hereby approved for connection to facilities within the Distributor’s Contract Service Area.Distributor Name: ____________________________________________________________________________________

Approved by: __________________________________Title: __________________________________Date: __________________

Denver Water office use only: Tap numbers: __________________ - __________________

Plan ID #: ___________________ Participation #: _______________________ Completion date: ____________