2019 Preliminary Application Form - Local Bridge Program - Connecticut

The Connecticut Department of Transportation has released this version of the "Preliminary Application Form - Local Bridge Program" on July 1, 2018.

This form may be used by all Connecticut residents: download the printable PDF by clicking the link below and use it according to the applicable legal guidelines.

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CONNECTICUT DEPARTMENT OF TRANSPORTATION
L
B
P
OCAL
RIDGE
ROGRAM
PRELIMINARY APPLICATION
Preliminary application is hereby made by the Town/City/Borough of __________________________
for possible inclusion in the Local Bridge Program for Fiscal Year
for the following structure:
2019
Bridge Location: ______________________________________________________________________
Bridge Number:
Structure Length:
feet Curb-to-Curb Width:
feet
%
%
Sufficiency Rating:
Priority Rating: _________
Evaluation & Rating Performed by:
____ State Forces
____ Others
If Others, Name of Professional Engineer:
Connecticut Professional Engineers License Number:
Engineering Firm:
Engineer’s Address:
Engineer’s E-mail Address:
Description of Existing Condition of Structure:
(attach description)
Description of Project Scope: _____________
(note Bridge Repair Code as per
current
Figure 5-1 of the
Local
; attach narrative/preliminary plans & specifications).
Bridge Program Manual
Name of Municipal Official to Contact: ___________________________________________________
Title: ___________________________ Telephone: ______________ Ext: ____ Fax: _____________
Mailing Address: _____________________________________________________________________
E-mail: _______________________________________
Anticipated Schedule:
(MM/DD/YYYY)
Public Meeting Conducted:
Design Completion:
Property Acquisition Completion:
Utilities Coordination Completion:
Construction Advertising:
Supplemental Application Submission:
(Not applicable for Federal Local Bridge Program Projects)
Start of Construction:
Completion of Construction:
Rev. 7/2018
CONNECTICUT DEPARTMENT OF TRANSPORTATION
L
B
P
OCAL
RIDGE
ROGRAM
PRELIMINARY APPLICATION
Preliminary application is hereby made by the Town/City/Borough of __________________________
for possible inclusion in the Local Bridge Program for Fiscal Year
for the following structure:
2019
Bridge Location: ______________________________________________________________________
Bridge Number:
Structure Length:
feet Curb-to-Curb Width:
feet
%
%
Sufficiency Rating:
Priority Rating: _________
Evaluation & Rating Performed by:
____ State Forces
____ Others
If Others, Name of Professional Engineer:
Connecticut Professional Engineers License Number:
Engineering Firm:
Engineer’s Address:
Engineer’s E-mail Address:
Description of Existing Condition of Structure:
(attach description)
Description of Project Scope: _____________
(note Bridge Repair Code as per
current
Figure 5-1 of the
Local
; attach narrative/preliminary plans & specifications).
Bridge Program Manual
Name of Municipal Official to Contact: ___________________________________________________
Title: ___________________________ Telephone: ______________ Ext: ____ Fax: _____________
Mailing Address: _____________________________________________________________________
E-mail: _______________________________________
Anticipated Schedule:
(MM/DD/YYYY)
Public Meeting Conducted:
Design Completion:
Property Acquisition Completion:
Utilities Coordination Completion:
Construction Advertising:
Supplemental Application Submission:
(Not applicable for Federal Local Bridge Program Projects)
Start of Construction:
Completion of Construction:
Rev. 7/2018
Local Bridge Program – FY
2019
Preliminary Application
Page 2
Bridge Number _____________, Town/City/Borough of _________________________
Preliminary Cost Figures:
Preliminary Engineering Fees (Include Breakdown of Fees)
$
Rights-of-Way Cost (If applicable)
$
Municipally Owned Utility Relocation Cost
$
Estimated Construction Costs (Include Detailed Estimate)
$
Construction Engineering (Inspection, Materials Testing)
$
Contingencies
$
(10% of Construction Costs Only)
0.00
Total Estimated Project Cost
$
Financial Aid Data:
NOTE: funding limited to Eligible Bridges as published at www.ct.gov/dot/localbridge or those found to be eligible in accordance with
current
Section 2.3 – Priority Lists of the
Local Bridge Program Manual.
Federal Reimbursement:
Total Estimated Project Cost multiplied by 80%:
Federal Aid Request
$
State Local Bridge Project Grant:
(Cannot be combined with Federal reimbursement)
Total Estimated Project Cost multiplied by 50%:
Project Grant Request: $ ____________________
Other Source of State or Federal funding received/applied for: $____________, State/Federal ________
Funding program: ________________________________
I hereby certify that the above is accurate and true, to the best of my knowledge and belief. I
also certify that this form has not been modified in any way from that distributed by the Department of
Transportation for FY
.
2019
Signature: ___________________________________ Date: ________________
Name: _________________________________ Title: ______________________
(Must be signed by Chief Elected Official, Town Manager, or other Officer Duly Authorized)
Return original signed applications to:
Mr. Francisco T. Fadul
, P.E.
Project Engineer for the Local Bridge Program
Connecticut Department of Transportation
2800 Berlin Turnpike, P.O. Box 317546
Newington, Connecticut 06131-7546
Rev. 7/2018

Download 2019 Preliminary Application Form - Local Bridge Program - Connecticut

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