S T A T E O F C O N N E C T I C U T

Office of the State Traffic Administration

Department of Transportation

2800 Berlin Turnpike

P.O. Box 317546

Newington, CT 06131-7546

Phone: (860) 594-3020 Fax: (860) 594-2377

Major Traffic Generator

Submission Cover Sheet

(To be used for Certificate or Administrative Decision Reviews)

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Upload CSV File:

Date:

(PLEASE FILL OUT COMPLETELY)

Development Information

Name of Facility*:

Address:

Town:

If Development spans more than 1 town, please select below:

Zip:

Town 2:

Town 3:

Land Use Codes

Existing Land Use Information:

ITE - LUC:

Land Use Codes (Existing):

	ITE - LUC	Description	Unit of Measure 1	Qty	Unit of Measure 2	Qty	Note

Proposed Expansion or Land Use Change Information:

ITE - LUC:

Land Use Codes (Proposed):

	ITE - LUC	Description	Unit of Measure 1	Qty	Unit of Measure 2	Qty	Note

Total Land Use Information:

ITE - LUC:

Total Land Use Information:

	ITE - LUC	Description	Unit of Measure 1	Qty	Unit of Measure 2	Qty	Note

Parking Information

Existing:

Net addition/reduction of parking spaces by expansion or land-use change:

Total within Certifiable Area:

# Designated Handicapped:

Consultant Information

Select Consultant:

Companies:

Add New/Edit Consultant:

Consultants in Companies:

Consultant Company Name:

Consultant Contact Person - Last Name:

Consultant Contact Person - First Name:

Consultant Address:

Consultant Address - P.O. Box:

Consultant Town:

Consultant State:

Consultant Zip:

Consultant Phone:

Consultant Fax:

Consultant Email:

Land Owner's Contact Information (You can add one or more land owners)

Note! You must click "Add Land Owner" button to have "Land Owner" info saved upon the final .csv file creation.

Add a Land Owner:

Land Owner's Corporate Name :

Land Owner's Contact for Written Correspondence:

Land Owner�s Address:

Town:

State:

Zip:

Phone:

Land Owner�s E-Mail:

Fax:

Selected Land Owners:

	Name	Contact	Address	Town	State	Zip	Phone	Email	Fax

Anticipated Full Time Jobs Created:

MS 4:

* Required Field

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Major Traffic Generator

Submission Cover Sheet

(PLEASE FILL OUT COMPLETELY)

Development Information

Land Use Codes

Parking Information

Consultant Information

Land Owner's Contact Information (You can add one or more land owners)

** Note! You must click "Add Land Owner" button to have "Land Owner" info saved upon the final .csv file creation. **

Note! You must click "Add Land Owner" button to have "Land Owner" info saved upon the final .csv file creation.