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Page 1 of 4 Effective 08/01/08 City of Loveland Tenant Finish – Interior Remodel Building Permit Application Submittal Checklist Plans Examiner Building/Accessibility Dave Sprague – 970-962-2526 Kenneth Wiseman – 970-962-2662 Fire Department Romeo Gervais – 970-962-2518 Sandra Friedrichsen – 970-962-2554 Engineering 2/Transportation Development Review Rich Becker – 970-962-2560 Electrical - Metering Craig Bialy – 970-962-3582 Electrical Kathleen Porter – 970-962-3561 Wastewater – Pre-treatment Bill Thomas – 970-962-3719 Planning Jeff McKee – 970-962-2723 John Stuart – 970-962-2722 Building Administration 970-962-2505 Larimer County Health & Environmental Svcs – SEPARATE SUBMITTAL Gena Hurd – 970-498-6776 DRAWINGS SHALL BE NO LARGER THAN 30X42 The information needed by each review agency must be bundled and labeled according to the following distribution requirements to help facilitate a timely review. If you need assistance contact the Building Division at (970) 962-2505 All building permit applications and required documents must be submitted by 12:00 noon on Friday for the Monday check-in date, or Tuesday for the Wednesday check-in date. The review cycle begins when an application is accepted at check-in. The check-in process is not a full review, but an opportunity to identify issues or missing drawings that will prevent a full review. A tenant finish application is required for all non-residential projects that are a building occupancy change, or a zoning change in use. For submittal requirements for additions or new construction, please refer to the Non-Residential and Multi-Family dwelling distribution sheet. Architectural plan set includes: Structural drawings, electrical drawings with 1-lines, mechanical/HVAC drawings, and plumbing drawings. Submittals shall be provided as noted for the individual agency breakdowns. All submitted drawings must have the same north orientation. The City of Loveland is currently utilizing the following codes: 2006 International Building code 2006 International Mechanical code 2006 International Plumbing code 2006 International Fuel Gas code 2006 International Energy Conservation code 2008 National Electrical code 2006 International Fire code Building Clerk/Permit Coordinator 1 Building Administration set to include: 1 – Completed and signed application All buildings proposing more than one occupiable space must submit 1 – 8 ½ x 11 detail indicating the maximum number of potential tenant spaces. The City of Loveland assigns all addresses of multi-unit buildings. 1 – Copy of this document with a check-mark () next to all items included in this check-in package, with signature and phone number of person submitting the documents for check-in at the bottom. Plans Examiner – Building Division/Accessibility 1 Plans Examiner set to include: 2 Sets of architectural, structural, and engineering plans – These stamps are required to be wet signed and stamped Architectural/structural drawings – wet signed and stamped Method of energy code compliance – wet signed and stamped Electrical plans and 1-lines – wet signed and stamped Mechanical/HVAC plans – wet signed and stamped Plumbing plans – wet signed and stamped Code analysis – wet signed and stamped Page 2 of 3 Effective 12/31/07 Plans Examiner continued 1 – Project manual, if applicable 1 – Structural calculations, if applicable 2 – Asbestos inspection report from a State approved asbestos inspector, if any demolition is being performed. 1 – Hazardous materials inventory with MSDS and quantities, if applicable 2 – Architectural building elevations with roof top units ghosted on the plans 2 – Copies of a letter indicating no new RTUs or rooftop penetrations may be submitted in lieu of the exterior elevation drawings, if no changes are being made. 2 – Rooftop plans with screening details of any roof top equipment, if applicable 2 – Mechanical equipment schedules 2 sets – Cut sheets and details of all exterior light fixtures along with a site plan identifying fixture locations, if any are being added with this tenant finish 2 sets – Floor plans with proposed square footages of uses Fire Prevention 1 Fire Prevention set to include: 1 – Architectural, structural, and engineered plans – signed and stamped Architectural/structural drawings – signed and stamped Method of energy code compliance – signed and stamped Electrical plans and 1-lines – signed and stamped Mechanical/HVAC plans – signed and stamped Plumbing plans – signed and stamped Code analysis – signed and stamped 1 – Project manual, if applicable 1 – Elevation, if there are changes to the exterior elevation. 1 – Hazardous materials inventory with MSDS and quantities, if applicable Planning 1 Planning set to include: 1 – Architectural building elevations with roof top units ghosted on the plans 1 – Copy of a letter indicating no new RTUs or rooftop penetrations may be submitted in lieu of the exterior elevation drawings, if no changes are being made. 1 – Rooftop plans with screening details of any roof top equipment 1 – Mechanical equipment schedule 1 set – Cut sheets and details of all exterior light fixtures along with a site plan identifying fixture locations 1 set – Floor plans with proposed square footages of uses Wastewater – Pre-treatment 1 Wastewater Pre-treatment set to include: 1 – Complete set of plumbing plans (must include kitchen, etc…) – signed and stamped 2 – Wastewater Discharge Surveys (attached). BP supplemental application for pre-treatment devices. Electrical 1 Electrical set to include: 1 – Electrical drawings and 1-lines from City XFMR to main panel including main disconnect, CT/PT can and/or meter socket. 1-line must specify that main disconnect, CT/PT can and/or meter socket are located on exterior of building. Existing metering equipment must be shown, along with any proposed changes to metering. 1 – Main panel size 1 – Secondary voltage A separate $300 or $1,000 (based on the scope of work) deposit for electrical engineering may be required prior to building permit submittal. Contact (970) 962-3561 to determine if this project is subject to this deposit. Electrical Metering 1 Electrical set to include: 1 – Electrical drawings and 1-lines from City XFMR to main panel including main disconnect, CT/PT can and/or meter socket. 1-line must specify that main disconnect, CT/PT can and/or meter socket are located on exterior of building. Existing metering equipment must be shown, along with any proposed changes to metering. 1 – Main panel size 1 – Secondary voltage 2 – Completed electrical worksheets (attached) – This document must be signed prior to submittal Engineering 2/Transportation Development Review 1 Engineering 2/TDR set to include 2 – Traffic worksheets (attached). The traffic worksheet is the minimum documentation required for initial review. A traffic memorandum or traffic study may be required, at the discretion of Engineering 2/TDR. 1 set – Floor plans with proposed square footages of uses Larimer County Health and Environmental Services SEPARATE SUBMITTAL to 1525 Blue Spruce Dr., Ft. Collins, CO 80524 is required if you meet any of the following criteria: Restaurants/Caterers Convenience stores Concession stands Markets/grocery stores Bars/nightclubs/social clubs Food processors Page 3 of 3 Effective 12/31/07 Food warehouses Hotels Health care facilities Child care facilities Schools Pools/spas Any project that includes a commercial kitchen Any project that is not serviced by public sewer If you meet any of these criteria, health department approval is required prior to building permit approval. 1 – Complete Health Department plan review application with plan review application fee 1 – Complete set of architectural drawings and engineering plans 1 – Site plan 1 – Mechanical/HVAC plans and schedules 1 – Plumbing plans and schedules 1 – Electrical plans 1 – Equipment specification manuals 1 – Proposed menu – food operations Contact the Health Department at (970)-498-6775 for additional assistance. You may choose to submit 8 full sets (refer to the Plans Examiner list) of drawings in lieu of providing the individual department breakdowns. Prior to issuance of a Certificate of Occupancy a complete set of drawings in CAD format must be submitted to the Loveland Fire Prevention Bureau. For additional information, contact them at 970-962-2536. Prior to issuance of a Certificate of Occupancy a “Certification of Installation” is required for establishments installing a pre-treatment device (interceptor, trap, etc). For additional information, contact 970-962-3719. If modifications to the fire suppression system or alarm system are necessary, a separate application must be submitted to the Loveland Fire Prevention Bureau. For additional information, contact them at 970-962-2536. RESUBMITTALS All comment responses shall be obtained directly through the Permit Coordinator. Comments may be available the day after the review cycle has finished. Partial comments are not provided, and partial resubmittals are not allowed. All resubmittals must be submitted through the Building Division and will go through the standard check-in process. All resubmittals must be submitted according to this distribution sheet. 8 copies of all revised sheets are required for all resubmittals, unless directed differently by the Permit Coordinator. All resubmittals must be stapled in the individual bundles as indicated on this distribution sheet. Only those sheets that have revisions should be resubmitted. A comment response is required indicating what changes have been made. All changes should also have a notation on the appropriate sheet(s) indicating the change. All projects are allowed 2 reviews before additional plan review fees are assessed. If additional plan review fees are assessed, they are charged on the hourly rate of $47.00/per hour for all review agencies. Revisions to approved projects are charged on the hourly rate of $47.00/per hour for all review agencies Signature of person submitting package for check-in Printed name of person submitting package for check-in Phone number of person submitting package for check-in Non-Residential WW Survey Page 1 of 6 January 2008 INDUSTRIAL PRETREATMENT PROGRAM Non-residential Wastewater Discharge Survey Section I - General Information A. Official Business Name: NAICS code: Doing business as (if different than above): Street Address: Unit: Zip: Mailing Address (if different): Phone number: Fax number: Web site: Business Owner Name: Address: City: State: Zip: Official Business Contact person (if different than above) Name Title B. Property Owner Name: Address: City: State: Zip: C. Is the business located in a common area shared by multiple tenants (food court, shopping center, business complex, office building, etc.)? Yes No Section II - Business Operation A. When did/will the business begin operations at this location? B. Business Category: Manufacturing Sales Service Repair Other (specify): C. Hours of Operation: D. Number of employees: Number of Shifts: Department of Water and Power Service Center • 200 North Wilson Avenue • Loveland, CO 80537 (970) 962-3000 • (970) 962-3400 FAX • (970) 962-2620 TDD www.cityofloveland.org Non-Residential WW Survey Page 2 of 6 January 2008 E. Check all activities this business performs: Anodizing Bakery Bar, Club, Drinking Places Barber / Hair styling Beverage Mfg. (all types) Body Shop (vehicle) Car / Truck / Heavy Machinery Washing Carpet/Upholstery cleaning Catering Chemical Etching Chemical Milling Chromating Coatings Crematory Dental Services Diaper Services Distributor Drum/barrel wash-out Dyeing Fabric Electroplating Electroless Plating Embalming Engraving Equipment repair/maint. Equipment Washing Fast food Finishing Processes Flammables / Explosives Food preparation / serving Furniture Manufacturing Fuel sale/supply Grocery Ground Water Remediation Hotel/Motel Jewelry Laboratory Laundromat (coin-op) Laundry, Commercial Laundry, Dry Cleaning Laundry, Industrial Lawn care Medical Services Machine shop Meat processing Office Painting Parts Washing/Degreasing Phosphating Photo Develop/processing Plastics processing Powder coating Printed Circuit Board Mfg Printing/Publishing Rendering Research: Restaurant Waste Collection/Disposal School / College Semi-conductor Mfg. Septic Tank Cleaning Silk Screening Slaughterhouse Small Engine repair/service Smelting Storage Stripping Tank / Piping Wash-out Transportation Services Vehicle Repair/Service Veterinarian Services Warehouse Wastewater treatment Water treatment X-ray services Other manufacturing (specify): Other commercial/industrial not listed (specify): F. Describe all production, manufacturing, and service operations: G. Will any wastewater other than restroom, break room, or bath/shower discharge to the sanitary sewer system? Yes No If yes, provide the following: (use additional sheet if necessary) Source Volume (gallons per day) E = Estimated M = Measured Non-Residential WW Survey Page 3 of 6 January 2008 Section III - Chemicals and Other Substances Place a (check mark) next to any that are used, stored, or produced at this facility. Place an “X” in front of those that could be present in the wastewater discharged from the facility. Volatiles Acrolein Acrylonitrile Benzene Bromoform Carbon tetrachloride Chlorobenzene Chlorodibromomethane Chloroethane 2-chloroethylvinyl ether Chloroform Dichlorobromomethane 1,2-dichlorobenzene 1,3-dichlorobenzene 1,4-dichlorobenzene 1,1-dichloroethane 1,2-dichloroethane 1,1-dichloroethylene 1,2-dichloropropane 1,3-dichloropropylene Ethylbenzene Methyl bromide Methyl chloride Methylene chloride 1,1,2,2-tetrachloroethane Tetrachloroethylene Toluene 1,2-trans-dichloroethylene 1,1,1-trichloroethane 1,1,2-trichloroethane Trichloroethylene Vinyl chloride Acid Compounds 2-chlorophenol 2,4-dichlorophenol 2,4-dimethylphenol 4,6-dinitro-o-cresol 2,4-dinitrophenol 2-nitrophenol 4-nitrophenol p-chloro-m-cresol Pentachlorophenol Phenol 2,4,6-trichlorophenol Base/Neutral Acenaphthene Acenaphthylene Anthracene Benzidine Benzo(a)anthracene Benzo(a)pyrene 3,4-benzofluoranthene Benzo(ghi)perylene Benzo(k)fluoranthene bis(2-chloroethoxy)methane bis(2-chloroethyl)ether bis(2-chloroisopropyl)ether bis (2-ethylhexyl)phthalate 4-bromophenyl phenyl ether Butylbenzyl phthalate 2-chloronaphthalene 4-chlorophenyl phenyl ether Chrysene Dibenzo(a,h)anthracene 3,3′-dichlorobenzidine Diethyl phthalate Dimethyl phthalate Di-n-butyl phthalate 2,4-dinitrotoluene 2,6-dinitrotoluene Di-n-octyl phthalate 1,2-diphenylhydrazine (as azobenzene) Fluroranthene Fluorene Hexachlorobenzene Hexachlorobutadiene Hexachlorocyclopentadiene Hexachloroethane Indeno(1,2,3-cd)pyrene Isophorone Napthalene Nitrobenzene N-nitrosodimethylamine N-nitrosodi-n-propylamine N-nitrosodiphenylamine Phenanthrene Pyrene 1,2,4-trichlorobenzene Pesticides Aldrin alpha-BHC beta-BHC gamma-BHC delta-BHC Chlordane 4,4′-DDT 4,4′-DDE 4,4′-DDD Dieldrin alpha-endosulfan beta-endosulfan Endosulfan sulfate Endrin Endrin aldehyde Heptachlor Heptachlor epoxide PCB-1242 PCB-1254 PCB-1221 PCB-1232 PCB-1248 PCB-1260 PCB-1016 Toxaphene Metals and Other Pollutants Aluminum Arsenic Antimony Barium Beryllium Boron Bromide Cadmium Cobalt Chromium Copper Cyanide Fluoride Iron Lead Magnesium Manganese Mercury Molybdenum Nickel Nitrogen, Nitrate, Nitrite Oil and Grease pH equal to/less than 5.0 pH equal to/more than 11.0 Phenols Phosphorus Radioactivity Selenium Silver Sulfate, Sulfide, Sulfite Surfactants Thallium Tin Titanium Zinc Oxygen demand (BOD, etc) Dissolved solids Suspended solids Section III (continued) Place a check mark () next to any that are used, stored, or produced at this facility. Place an “X” in front of those that could be present in the wastewater discharged from the facility. Toxic Pollutants Asbestos Hazardous Substances Acetaldehyde Allyl alcohol Allyl chloride Amyl acetate Aniline Benzonitrile Benzyl chloride Butyl acetate Butylamine Captan Carbaryl Carbofuran Carbon disulfide Chlorpyrifos Coumaphos Cresol Crotonaldehyde Cyclohexane 2,4-D (2,4-Dichlorophenoxy acetic acid) Diazinon Dicamba Dichlobenil Dichlone 2,2-Dichloropropionic acid Dichlorvos Diethyl amine Dimethyl amine Dintrobenzene Diquat Disulfoton Diuron Epichlorohydrin Ethion Ethylene diamine Ethylene dibromide Formaldehyde Furfural Guthion Isoprene Isopropanolamine Dodecylbenzenesulfonate Kelthane Kepone Malathion Mercaptodimethur Methoxychlor Methyl mercaptan Methyl methacrylate Methyl parathion Mevinphos Mexacarbate Monoethyl amine Monomethyl amine Naled Napthenic acid Nitrotoluene Parathion Phenolsulfanate Phosgene Propargite Propylene oxide Pyrethrins Quinoline Resorcinol Strontium Strychnine Styrene 2,4,5-T (2,4,5-Trichlorophenoxy acetic acid) TDE (Tetrachlorodiphenylethane) 2,4,5-TP [2-(2,4,5-Trichlorophenoxy) propanoic acid] Trichlorofan Triethanolamine dodecylbenzenesulfonate Triethylamine Trimethylamine Uranium Vanadium Vinyl acetate Xylene Xylenol Zirconium Other chemicals not listed: Are there any proprietary chemical products? Yes No Are there any polymer products? Yes No Are there any flammables? Yes No Are there any explosives? Yes No Non-Residential WW Survey Page 5 of 6 January 2008 Section IV – Wastes generation, Treatment, and Storage A. Identify the wastes generated, treated, stored, and disposal method (use additional sheet if necessary). Type of Waste Generate (Y / N) Quantity per month, indicate gallons (G) or pounds (P) Yes or No Hazardous Waste On-site treatment Discharged to Sewer Hauled off site Acids Alkalis Amalgam Biological Photo Lab Ink or dyes Oil Paint or Resins Pesticides Pharmaceutical Solvent/Thinners Sludge X-ray Other: Other: B. List all treatment and storage devices (such as grease interceptor, sand/oil interceptor, waste oil tanks, filters, screens, or any biological, chemical, or physical treatment). C. For any waste hauled off-site in A or B above provide the following: D. Are there floor drain(s) in the production, storage, or use areas for any items listed in Section III or Section IV.A above? Yes No E. Indicate which of the following are/will be in effect: Closure Plan? RCRA plan to handle hazardous waste? Spill Prevention Plan? Plan for handling solvents and/or solvent wastes? Treatment/Storage Device Capacity (unit of measure) Waste Hauler Name City, State Phone Number Non-Residential WW Survey Page 6 of 6 January 2008 Section V - Other If you received this survey as part of a building permit application also complete the following: A. Building permit #: - Provide a complete description of all work to be performed under this building permit: B. Identify if any of the following will discharge to the sanitary sewer system: Sump pump Loading dock drain Water fountain feature Swimming pool Outside drain Roof drain Section VI - Survey Certification The statement below must be signed as follows (reference Federal regulation 40 CFR 403.12.l ): (check the applicable box): (1) By a responsible corporate officer, if a corporation. a responsible corporate officer means: (i) a president, secretary, treasurer, or vice-president of the corporation in charge of a principal business function, or any other person who performs similar policy- or decision-making functions for the corporation, or (ii) The manager of one or more manufacturing, production, or operating facilities, provided the manager is authorized to make management decisions which govern the operation of the regulated facility and assure environmental compliance. (2) By a general partner or proprietor if a partnership, or sole proprietorship respectively. By a duly authorized representative of the individual designated in Part 1 or 2 above if: (i) The authorization is made in writing by the individual described in Part 1 or 2; (ii) The authorization specifies either an individual or a position having responsibility for the overall operation of the facility from which the discharge originates, such as the position of plant manager, field superintendent, or a position of equivalent responsibility, or having overall responsibility for environmental matters for the company; and (iii) the written authorization is submitted to the City. (provide written documentation): I certify under penalty of law that this information and all attachments submitted is, to the best of my knowledge and belief, true, accurate, and complete. I am aware that there are significant penalties for submitting false information, including the possibility of fine and imprisonment for knowing violations. Signature Title Printed Name Date The City is required by federal law to obtain and maintain information about commercial and industrial users of the sewer system. The information you provide will assist us in monitoring the types of waste discharged into the sanitary sewer system and determine if further actions are required to protect the City‟s wastewater collection and treatment system, worker health and safety, and the environment from any adverse impact that may occur when certain wastes are discharged into the sewer system. The survey is intended to cover a variety of business types. Complete the survey to the best of your knowledge. If an item does not apply please indicate so with “NA” to show it was considered. Section I – General Information A. Official Business Name – enter the “official” name of the business/company that is/will be the occupant of the premises. It is not the engineer, contractor, consultant, attorney, or other contractual person providing a service to the business. Enter the name of the business if it is different from the “official business name.” NAICS is an acronym for North American Industry Classification System (it replaced the SIC code). If the NAICS is unknown, use the Standard Industrial Classification (SIC) code if known, otherwise leave it blank. Business Owner – is the person/company who owns the business in „A‟ above. Section II – Business Information F. Be specific in describing what is/will be sold, repaired, manufactured/produced, distributed, or the type of service(s) performed. Section III – Chemicals and Substances There are two parts of this Section. You may need to refer to the Material Safety Data Sheet (MSDS) received with a product. Section IV – Waste generation, Treatment, and Storage Floor drains (trench drains) are drainage fixtures that typically sit flush with the floor and usually connect to the city sewer system. The City needs to know what potentially goes down the drain and where it is located. Food service establishments, car wash, auto repair shops, machine shops, some manufacturing facilities, are just a few of the businesses required to have treatment devices. Section V – Other Failure to complete this part of the survey will delay a building permit application. Section 13.08.101 of the Loveland Municipal Code states downspouts, roof drainage, yard drainage, foundation drains (underdrains), areaway drains, groundwater, surface water (runoff), water from natural springs, and subsurface drainage shall not be connected, directly or indirectly, to the city‟s sanitary sewer system unless such connection is first approved in writing by the Director of the Department of Water and Power. Section VI – Survey Certification This section must be signed by an official of the business listed in Section I (owner, CEO, President, etc…). If you are a “duly authorized representative” you must provide written documentation from an appropriate business official that you have the authority to complete the survey on their behalf. Revised January 21, 2009 Page 3 of 3 Attachment C Transportation Worksheet This form must be completed and submitted when requesting a waiver of the TIS submittal and compliance requirements. This form is not required with building permit applications for residential projects proposing twelve dwelling units or less and no substantial access changes on a collector or arterial roadway. Project Name: Date: Property Legal Description (lot, block, subdivision) Developer: By: Title: Address: Phone #: Fax #: Email: NON-RESIDENTIAL DEVELOPMENT: Provide the following information for all non-residential projects: A. Existing use: 1. Description of existing land use: (if none, proceed with Proposed Use) 2. Existing building area (square footage) for above use(s): (2) 3. Number of employees on site each day: (3) 4. Daily trip ends for employees [multiply line (3) by the number 4]: (4) 5. Number of customers on site each day: (5) 6. Daily trip ends for customers [multiply line (5) by the number 2] (6) 7. Number of venders on site each day (include trash, ups, etc): (7) 8. Daily Trip Ends for venders [multiply. line (7) by the number 2]: (8) 9. Total Vehicular Daily Trip Ends [line (4) plus line (6) plus line (8)]: (9) 10. Source of trip generation data (circle one): ITE, business records, traffic engineer, personal estimate, Revised January 21, 2009 Page 3 of 3 other: . Attach documentation to support your data. 11. Number of accesses existing onto the public street(s) from this property: 12. Number of pedestrians visiting the site each day: 13. Number of bicyclists visiting the site each day: 14. Do sidewalks exist along street(s) adjacent to the property? Yes___ No___ 15. Are bike lanes existing (striped) along major collector or arterial street(s) adjacent to this property (on both sides of the street)? Yes___No___ NA___ 16. Is the property adjacent to a major collector or arterial street as shown on the City‟s transportation plan? Yes___ No___ B. Proposed use: 1. Description of proposed land use: 2. Proposed building area (square footage) for above use(s): (2) 3. Anticipate number of employees on site each day: (3) 4. Daily Trip Ends for employees [multiply line (3) by the number 4]: (4) 5. Anticipate number of customers on site each day: (5) 6. Daily trip ends for customers [multiply line (5) by the number 2]: (6) 7. Anticipate number of venders on site each day: (7) 8. Daily Trip Ends for venders [multiply line (7) by the number 2]: (8) 9. Total Daily Trip Ends [line (4) plus line (6) plus line (8)]: 10. Source of trip generation data (circle one): ITE, business records, traffic engineer, personal estimate, other: . Attach documentation to support your data. 11. Proposed number of accesses onto the public street(s) from this property (does NOT include any existing accesses proposed to remain for use): 11. Number of existing accesses proposed to remain and be used: 13. Number of pedestrians visiting the site each day: 14. Number of bicyclists visiting the site each day: 15. Are sidewalks proposed to be installed (or exist in good condition) along the street(s) adjacent to the property? Yes___ No ___ Revised January 21, 2009 Page 3 of 3 16. Are bike lanes existing or proposed to be installed (to be striped with any required no parking signs installed) along major collector or arterial street(s) adjacent to this property (on both sides of the street)? Yes___ No___ NA___ 17. Is the property adjacent to a major collector or arterial street as shown on the City‟s 2020 transportation plan? Yes___ No___ If the total trip new trips, (that is the difference between the daily trip ends calculation for any existing use and the total daily trip ends calculated for the proposed use), is less than 200 and if peak hour and/or daily traffic counts demonstrate that the existing traffic plus the site generated traffic volumes are within the limits set by City Street Standards, the applicant may request a waiver of the Traffic Impact Study submittal requirements by signing below. Signature Date Full TIS Required: Intermediate TIS Required: TIS Waived: By: Date: REQUEST FOR ELECTRIC SERVICE (To be submitted by Electrical Designer or Electrical Contractor) A completed form must be submitted with any permit application that includes electrical work. Please call (970) 962-3561 to schedule an appointment with the Field Engineering group to review the form. - COMPLETE ALL SECTIONS - - ATTACH COPIES OF THE ELECTRICAL ONE LINE DRAWING AND POWER PLAN – doc1 1 Contact Information Name of Person Submitting Request: _________________________________________ Date _______/_______/________ Company Name: ________________________________________________ ________ Phone Number (____)______-________ Fax (____)______-_________ email ____________________________________________ Customer Information Billing Information Customer Name: _______________________________________________ Mailing Address: ________________________________________________ Phone # (____)_____-_________ email _____________________________ Bill To: ______________________________________________________ Mailing Address: ________________________________________________ Phone # (____)_____-_________ email _____________________________ Electrical Contractor Information Company Name: _________________________________________________ Contact Person: _________________________________________________ Phone Number (____)______-_________ Fax (____)______-_________ email _____________________________________________ Location Information Service Address: _______________________________________________________________________ Unit#_________________ If this is part of a multi-occupancy building, give the building’s entire address range: _________________________________________________________ New Construction Existing Structure Addition to Existing Structure Demolition Within City Limits? Yes No Type of Building: Single Occupancy Multi-Occupancy Commercial Multi-Occupancy Core & Shell Only Multi-Occupancy Residential Request Type New Service Upgrade Existing Service Increase Existing Service Entrance size (with no service upgrade) Add new Meter(s) to Existing Service (with no service upgrade) Remove Existing Meter(s), service to remain Remove Existing Meter(s) and Service Modification of Existing Tenant Space(s) Other _________________________________________________________________________________ Electrical Load Information New Equipment Load New Equipment Load HVAC Equipment (Tons) ________ ______ Tot. KW X-Ray Equipment ______ KW Refrigeration Equipment (Tons) ________ ______ Tot. KW Washer/Dryer(s) ______ KW Elec. Heat ______ KW Machinery Number: ____ ______ Tot. HP Water Heating ______ KW Exhauts Fans Number: ____ ______ Tot. HP Lighting ______ KW Pumps Number: ____ ______ Tot. HP Outlets ______ KW Small Motors Number: ____ ______ Tot. HP Office Equipment ______ KW Compressors Number: ____ ______ Tot. HP Kitchen Equipment ______ KW Misc. ______ KW Computers ______ KW ______ KW Snow Melting Equipment ______ KW ______ KW Thermoplastic Injection Equipment ______ KW Future Equipment ______ KW Boiler ______ KW (Itemize on separate sheet) Elevators ______ KW Signs ______ TOTAL ______ KW REQUEST FOR ELECTRIC SERVICE, (continued) - COMPLETE ALL SECTIONS - Doc1 2 Service Information Existing Service Information N/A – No Existing Service at this location New Service Information N/A – Existing Service and Service Entrance will remain unchanged Service Type: Underground Overhead Transformer Number: ____________ Transformer Size: ____________kVA Service Type: Underground Overhead Temporary Service Permanent Service Voltage: 120/240V 1P3W 120/208V 1P3W 120/208V 3P4WΥ 277/480V 3P4WΥ 240V 3P3WΔ 480V 3P3WΔ 240V 3P4WΔ Voltage: 120/240V 1P3W 120/208V 1P3W 120/208V 3P4WΥ 277/480V 3P4WΥ Service Terminates in: Main Disconnect Gutter Metering Equipment Service Entrance Size: ______________Amps Service Terminates in: Main Disconnect Gutter Metering Equipment Service Entrance Size: ______________Amps Conductors/phase: ______ Conductor Size: ____________ Conduits: Number __________ Size ____________ Conductors/phase: ______ Conductor Size: ____________ Conduits: Number __________ Size ____________ Meter Information Existing Meter Information N/A – No Existing Meters at this location For multi-occupancy buildings, list all meters connected to this service New Meter Information N/A – Existing Meters and Service will remain unchanged For multi-occupancy buildings, tenant meters will only be installed for spaces being finished under this permit. Core & Shell only projects will only receive a house meter on the C&S permit. Max. Potential # of Meters at Build Out: ____Commercial ____Residential Meter Number ____________ ____________ ____________ ____________ ____________ ____________ ____________ ____________ Size ________Amps ________Amps ________Amps ________Amps ________Amps ________Amps ________Amps ________Amps Meter will: Remain Be Removed Remain Be Removed Remain Be Removed Remain Be Removed Remain Be Removed Remain Be Removed Remain Be Removed Remain Be Removed Size and Number of New Meters Being Requested Commercial Meters ___ Ph ___ W ______ /______ V Number of Meters Needed: ________ @ 200 Amps (or less) ________ @ 400 Amps ________ @ ________ Amps Residential Meters ___ Ph ___ W ______ /______ V Number of Meters Needed: ________ @ 200 Amps (or less) ________ @ 400 Amps (Incl. CL320) ________ @ ________ Amps Comments: _______________________________________________________________________________________________________ _______________________________________________________________________________________________________ _______________________________________________________________________________________________________ Do not write below this line Field Engineering Review ________________________________________ Date ____________________________ One Line Received Power Plan Received If No, Why? ____________________________________________________
