Illinois Major Bridge Program Application

Bridge IDOT County: Name: District: Structure City: Number(s): Facility Facility/Fea Carried: ture Owner: Jurisdiction Yes No al Type of Rehab Replace Date of Work: Last Sufficiency Number of Functional Rating Lanes: Class Load Yes No List the Posted: load ADT (from ADTT: ADT’: ADT Year: SI&A (Do not use Future/Projected ADT or AADT counts here. Use the last official recorded counts.)

FY REQUEST (in dollars) Entire Major Major Bridge Request (PE,Project CE, Bridge(CE, (CE, Construction) ROW, Constructio Total Cost Federal Share (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: Printed 4/4/2018 OPP 2171 (Rev. 07/24/14) E-mail:

Printed 4/4/2018 OPP 2171 (Rev. 07/24/14)