"Time Extension Request for Supplemental Application - Local Bridge Program" - Connecticut

Time Extension Request for Supplemental Application - Local Bridge Program is a legal document that was released by the Connecticut Department of Transportation - a government authority operating within Connecticut.

Form Details:

  • Released on March 1, 2014;
  • The latest edition currently provided by the Connecticut Department of Transportation;
  • Ready to use and print;
  • Easy to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

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

ADVERTISEMENT
ADVERTISEMENT

Download "Time Extension Request for Supplemental Application - Local Bridge Program" - Connecticut

629 times
Rate (4.5 / 5) 31 votes
CONNECTICUT DEPARTMENT OF TRANSPORTATION
LOCAL BRIDGE PROGRAM
Time Extension Request
__________
Bridge Number:
Project Number: ________________
Bridge Location: _______________________________________________________________
The Town/City/Borough of ____________________hereby requests an extension of the
deadline for filing the Supplemental Application for the following reason(s):
Engineer Responsible for Project Design:
Name: ______________________________
Firm: ______________________________
Mailing Address: _____________________________________________________________
Telephone Number:
_____Ext_______ FAX:
______
E-Mail:
________
Municipal Information:
Name of Official to Contact:
Mailing Address:
Telephone Number:
_____Ext_______ FAX:
______
E-Mail:
Project Cost Data
Preliminary
Updated
Preliminary Engineering Fees
$
$
Rights-of-Way Cost
$
$
(If Applicable)
Municipal Utility Relocation
$
$
Estimated Construction Costs
$
$
(Include Detailed Estimate)
Construction Engineering
$
$
Contingencies
$
$
(10% of Construction Costs Only)
0.00
0.00
Total Estimated Project Cost
$
$
Rev. 3/2014
CONNECTICUT DEPARTMENT OF TRANSPORTATION
LOCAL BRIDGE PROGRAM
Time Extension Request
__________
Bridge Number:
Project Number: ________________
Bridge Location: _______________________________________________________________
The Town/City/Borough of ____________________hereby requests an extension of the
deadline for filing the Supplemental Application for the following reason(s):
Engineer Responsible for Project Design:
Name: ______________________________
Firm: ______________________________
Mailing Address: _____________________________________________________________
Telephone Number:
_____Ext_______ FAX:
______
E-Mail:
________
Municipal Information:
Name of Official to Contact:
Mailing Address:
Telephone Number:
_____Ext_______ FAX:
______
E-Mail:
Project Cost Data
Preliminary
Updated
Preliminary Engineering Fees
$
$
Rights-of-Way Cost
$
$
(If Applicable)
Municipal Utility Relocation
$
$
Estimated Construction Costs
$
$
(Include Detailed Estimate)
Construction Engineering
$
$
Contingencies
$
$
(10% of Construction Costs Only)
0.00
0.00
Total Estimated Project Cost
$
$
Rev. 3/2014
LOCAL BRIDGE PROGRAM
Time Extension Request
__________
Bridge Number:
Project Number: ________________
Bridge Location: _______________________________________________________________
Scope of Proposed Project:
(Description of the work to be done on the bridge project)
Revised Project Schedule:
(MM/DD/YYYY)
Final Design (Accepted by Municipality)
____________________________________
Public Hearing (Conducted)
____________________________________
Submit Supplemental Application
____________________________________
Construction Advertising
____________________________________
Construction Contract Award
____________________________________
Construction Start
____________________________________
Construction Complete
____________________________________
Audit Submittal
____________________________________
Sincerely,
Signed ____________________________________
Date
_______________________
Name: ____________________________________
Title
____________________________________
Return to:
Mr. Francisco T. Fadul
Project Engineer for the Local Bridge Program
Connecticut Department of Transportation
P.O. Box 317546
Newington, Connecticut 06131-7546
Rev. 3/2014
Page 2
Page of 2