Illinois Major Bridge Program Application Bridge Name: IDOT District: County: Structure Number(s): City: Facility Facility/Feature Crossed: Carried: Jurisdictional Agreement Required: Yes No Type of Replace Date of Last Inspection: Work: Sufficiency Rating Number of Lanes: Functional Class Value: (SI&A Sheet): Load Posted: Yes No List the load posting (if yes): ADT ADT ADTT: ADT’: (from SI&A Sheet): Year: (Do not use Future/Projected ADT or AADT counts here. Use the last official recorded counts.) FY REQUEST (in dollars) Entire Project Cost * Major Bridge Total Major Bridge Request (PE, CE, ROW, Utilities, Construction) (CE, Construction) (CE, Construction) Total Cost Federal (80%) Non-Federal Matching (20%) *Cost estimate of bridge and bridge approach work to be used in rating factor calculation. Describe construction activity planned (rehabilitation of substructure, superstructure, deck, main span, etc. or total replacement) below and attach a current briefing about the entire project: Special Consideration: Contact Person Information Name: Phone: Street City: Address: E-mail:
Illinois Major Bridge Program Application Bridge Name: IDOT District: County: Structure Number(s): City: Facility Carried: Facility/Feature Crossed: Jurisdictional Agreement Required: Yes No Type of Work: Replace Date of Last Inspection: Sufficiency Rating (SI&A Sheet): Number of Lanes: Functional Class Value: Load Posted: Yes No List the load posting (if yes): ADT (from SI&A Sheet): ADTT: ADT’: ADT Year: (Do not use Future/Projected ADT or AADT counts here. Use the last official recorded counts.) FY REQUEST (in dollars) Entire Project Cost * Major Bridge Total Major Bridge Request (PE, CE, ROW, Utilities, Construction) (CE, Construction) (CE, Construction) Total Cost Federal (80%) Non-Federal Matching (20%) *Cost estimate of bridge and bridge approach work to be used in rating factor calculation. Describe construction activity planned (rehabilitation of substructure, superstructure, deck, main span, etc. or total replacement) below and attach a current briefing about the entire project: Special Consideration: Contact Person Information Name: Phone: Street Address: City: E-mail:
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