"Supplemental Application Form - Local Bridge Program" - Connecticut

Supplemental Application Form - 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 February 1, 2014;
  • The latest edition currently provided by the Connecticut Department of Transportation;
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Download "Supplemental Application Form - Local Bridge Program" - Connecticut

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C
D
O
T
ONNECTICUT
EPARTMENT
F
RANSPORTATION
LOCAL BRIDGE PROGRAM
S
A
UPPLEMENTAL
PPLICATION
C.G.S. SECTIONS 13a-175p through 13a-175u, as Amended by P.A. 13-239
Supplemental Application is hereby made by the Town/City/Borough of _____________
for consideration for funding under the provisions and regulations of the Local Bridge Program
for Fiscal Year
for the following structure:
Bridge Number:
State Project Number: __________________
Bridge Location:
Span Length (existing/proposed):
/
feet
Width (existing/proposed):
/
CT Professional Engineer Responsible for Project Design:
Name: _____________________________________________________________________
Firm:
_____________________________________________________________________
License No.:
Telephone:
FAX: _______________
Street Address: ______________________________________________________________
City, State, ZIP: ______________________________________________________________
E-Mail:
Municipal Information:
Name & Title of Official Contact:
Street Address:
City, State, ZIP: ______________________________________________________________
Telephone Number:
FAX:
E-Mail:
Project Schedule:
(MM/DD/YYYY)
Final Design (Accepted by Municipality)
________________________
Rights-of-Way (Acquisition Complete)
________________________
Utilities (Coordination Completion)
________________________
Public Meeting (Conducted)
________________________
Construction Advertising
________________________
Construction Contract Award
________________________
Construction Start
________________________
Construction Complete
________________________
Audit Submittal
________________________
Rev. 2/2014
C
D
O
T
ONNECTICUT
EPARTMENT
F
RANSPORTATION
LOCAL BRIDGE PROGRAM
S
A
UPPLEMENTAL
PPLICATION
C.G.S. SECTIONS 13a-175p through 13a-175u, as Amended by P.A. 13-239
Supplemental Application is hereby made by the Town/City/Borough of _____________
for consideration for funding under the provisions and regulations of the Local Bridge Program
for Fiscal Year
for the following structure:
Bridge Number:
State Project Number: __________________
Bridge Location:
Span Length (existing/proposed):
/
feet
Width (existing/proposed):
/
CT Professional Engineer Responsible for Project Design:
Name: _____________________________________________________________________
Firm:
_____________________________________________________________________
License No.:
Telephone:
FAX: _______________
Street Address: ______________________________________________________________
City, State, ZIP: ______________________________________________________________
E-Mail:
Municipal Information:
Name & Title of Official Contact:
Street Address:
City, State, ZIP: ______________________________________________________________
Telephone Number:
FAX:
E-Mail:
Project Schedule:
(MM/DD/YYYY)
Final Design (Accepted by Municipality)
________________________
Rights-of-Way (Acquisition Complete)
________________________
Utilities (Coordination Completion)
________________________
Public Meeting (Conducted)
________________________
Construction Advertising
________________________
Construction Contract Award
________________________
Construction Start
________________________
Construction Complete
________________________
Audit Submittal
________________________
Rev. 2/2014
LOCAL BRIDGE PROGRAM
S
A
UPPLEMENTAL
PPLICATION
Existing Conditions: Attach description of existing conditions, including engineer’s evaluation.
Scope of Proposed Project: Attach detailed description of the proposed Project, including Final
Plans, Specifications, Detailed Estimates & other pertinent data.
Checklist:
____ Plans
____ Specifications
____ Engineer’s Final Estimates
____ Load Rating Documentation
____ R.O.W. (if applicable)
____ Utilities (if applicable)
____ Hydraulic Design Report – must include compact disk (if applicable)
____ Scour Evaluation Report – must include compact disk (if applicable)
____ Municipal Meeting Minutes
____ All Permits Acquired: Local, State, Federal (as applicable)
Project Cost Data
Preliminary
Updated
Preliminary Engineering Fees
$
$
(Include Breakdown of Fees)
Rights-of-Way Cost
$
$
(If Applicable)
Municipal Utility Relocation
$
$
Estimated Construction Costs
$
$
(Include Detailed Estimate)
Construction Engineering/Incidentals $
$
(Inspection, Materials Testing)
Contingencies
$
$
(10% of Construction Costs Only)
0.00
0.00
Total Estimated Project Cost
$
$
Financial Aid Data
Project Grant:
Municipality’s allowable grant percentage: __________%
0.00
0.00
$
x _________% = $ ______________________________
(Total Project Cost)
(Grant %)
(Total Grant Amount)
Page 2
Rev. 2/2014
LOCAL BRIDGE PROGRAM
S
A
UPPLEMENTAL
PPLICATION
CERTIFICATIONS:
I,
,
, duly authorized
name
title
by the (Town, City, Borough) of
as so signified by
the attached authorization, do certify and attest to the following:
1.
Approval and acceptance of all plans, specifications and estimates. Any digressions
from AASHTO and Connecticut Highway Design Manual guidelines have been
made in accordance with Section 13a-86a of the Connecticut General Statutes and
documentation has been retained in the project records.
2.
That all R.O.W. activities associated with the project have been addressed or will
be completed by the start of construction and, by a certified appraiser, that the
purchase price of all properties being acquired represents the fair market value of
such property.
3.
That the Municipality owns or has the responsibility for maintaining the structure
for which funding is sought and will be responsible for all future maintenance of
the structure.
4.
That all public and private utility relocations have been addressed.
5.
That the design loading for the structure complies with the requirement of the
Regulations for the Local Bridge Program.
6.
That all permits required from Federal, State, and local agencies have been
obtained, and all applicable permits, regulations and executive orders will be
complied with.
7.
That this project complies with National Flood Insurance Program requirements
and the Municipality’s Flood Management ordinance or regulations, if applicable.
8.
That the hydraulic design is in conformance with the requirements of the program
regulations, and that an appropriate scour evaluation has been performed.
9.
That separate accounts have been established specifically for this project and all
additions or disbursements will be made therefrom.
Signed
Date ________________________
Title
_________________________________
Municipal Seal
Page 3
Rev. 2/2014
LOCAL BRIDGE PROGRAM
S
A
UPPLEMENTAL
PPLICATION
CERTIFICATIONS By a Connecticut Licensed Professional Engineer:
I,
, do hereby certify:
name
1.
That the design loading complies with the requirements of the program regulations.
2.
That the completed structure is designed to have at least a 20-year life.
3.
That the design reflects the latest AASHTO LRFD Bridge Design Specifications
requirements for structures of that type, or previously approved digressions from
those standards based upon sound engineering judgment.
4.
That the geometric design reflects the latest Connecticut Highway Design Manual
requirements, or reasonable digressions from those standards based upon sound
engineering judgment.
5.
That the hydraulic design is in conformance with the requirements of the program
regulations, and that an appropriate scour evaluation has been performed.
6.
That any deviations from AASHTO and ConnDOT standards have been
authorized by the municipality, do not present an increased risk to the public, and
have considered all factors listed in Section 13a-86a of the Connecticut General
Statutes.
Signed ___________________________________
Date ______________________
Title _____________________________________
_______________________
Conn. P. E. Registration
(Stamp or Seal)
By a Certified Appraiser: (If Applicable)
I, ____________________________________, hereby certify that the appraised property
values reflect the current fair market value and are fair and reasonable.
Signed ___________________________________
Date ______________________
Title
______________________
Certification Number
Page 4
Rev. 2/2014
RESOLUTION
Project Description:
Local Bridge Program
State Project No. ____________
Bridge Number:
Bridge Location:
Town/City/Borough of _____________________________________
Be it RESOLVED, that,
, _______________________
name
title
of the Town/City/Borough of ____________________ is authorized to sign the LOCAL
BRIDGE PROGRAM SUPPLEMENTAL APPLICATION and any associated agreements
between the State of Connecticut and the Town/City/Borough of ________________________
for _______________________________________, Bridge No.__________.
(road carried over feature crossed)
ADOPTED by the________________________________ of the Town/City/Borough of
(legislative body)
__________________________, Connecticut
on
.
(date)
(Municipal Seal)
______________________________
____________
Signature of Clerk
Date