Form EXC-1 "Work Performance Request (Pursuant to the Provisions of Section 13b-30 of the General Statutes of Connecticut)" - Connecticut

What Is Form EXC-1?

This is a legal form that was released by the Connecticut Department of Transportation - a government authority operating within Connecticut. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on January 1, 2016;
  • The latest edition provided by the Connecticut Department of Transportation;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form EXC-1 by clicking the link below or browse more documents and templates provided by the Connecticut Department of Transportation.

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Download Form EXC-1 "Work Performance Request (Pursuant to the Provisions of Section 13b-30 of the General Statutes of Connecticut)" - Connecticut

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FORM NO. EXC-1 rev. 01/16
State of Connecticut
DEPARTMENT OF TRANSPORTATION
To:
The Commissioner of Transportation
PO Box 317546
Newington, CT
Pursuant to the provisions of Section 13b-30 of the General Statutes of Connecticut, as revised, you are
requested to perform the following work in the fiscal year ending June 30, 20___.
Department:_____________________________________________________________________________
Name of Agency:_______________________________________________ Town:____________________
Name of person familiar with work to be done:__________________________________________________
Telephone:______________________________ email:____________________________________
Description of work to be done:
____Maintenance
____Improvement ____Snow Removal
____Salt ____Liquid Magnesium
Location:
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
Date Requested:_________ By:_________________________________ Title:________________________
SPACE BELOW FOR DEPARTMENT OF TRANSPORTATION USE
Estimated Cost of Proposed Project:_________________________ Estimated by:______________________
Type of Work:____________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
Reviewed by:_______________________________________________________ Date:________________
District Maintenance Director
Reviewed/Approved by:______________________________________________ Date:________________
Transportation Maintenance Administrator
FORM NO. EXC-1 rev. 01/16
State of Connecticut
DEPARTMENT OF TRANSPORTATION
To:
The Commissioner of Transportation
PO Box 317546
Newington, CT
Pursuant to the provisions of Section 13b-30 of the General Statutes of Connecticut, as revised, you are
requested to perform the following work in the fiscal year ending June 30, 20___.
Department:_____________________________________________________________________________
Name of Agency:_______________________________________________ Town:____________________
Name of person familiar with work to be done:__________________________________________________
Telephone:______________________________ email:____________________________________
Description of work to be done:
____Maintenance
____Improvement ____Snow Removal
____Salt ____Liquid Magnesium
Location:
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
Date Requested:_________ By:_________________________________ Title:________________________
SPACE BELOW FOR DEPARTMENT OF TRANSPORTATION USE
Estimated Cost of Proposed Project:_________________________ Estimated by:______________________
Type of Work:____________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
Reviewed by:_______________________________________________________ Date:________________
District Maintenance Director
Reviewed/Approved by:______________________________________________ Date:________________
Transportation Maintenance Administrator