2019 Preliminary Application Form - Local Bridge Program - Connecticut

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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

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