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iJ <br /> Project Scope of Work • <br /> (list what you will do,along with the schedule) Loan Request(Costs) <br /> What When What How much <br /> Engineering Report(Preliminary 0 <br /> Design and Revisions 2/10 Engineering) _ „ .,. <br /> Environmental Review(SERP) <br /> Cultural Review(Section 106 of NHPA) <br /> LandlRight-of-Way Acquisition <br /> Permits <br /> Public Involvement/Information <br /> Preparation of Bid Documents 2/1176,470 <br /> Bid Documents(Design Engineering) <br /> Award of Construction Contract 6/11 800,000' <br /> Construction <br /> Liaison w/DOH 6/112,500 <br /> DOH Review/Approval Fees <br /> 10% Contingency 6/11 87,897 <br /> Contingency <br /> Sales Tax @ 9.2% 6/1188,952 <br /> Other Fees: (Sales or Use Taxes) <br /> Service Meters (Purchase and <br /> Installation) <br /> Audit Costs <br /> Other(describe): <br /> Other(describe): I <br /> Other(describe): <br /> .__.- ..............:. ......._,.. <br /> Other(describe): <br /> DWSRF Funding Request TOTAL $ 1055819 <br /> Loan Fee (1.00%of the Total) $ 10,558 <br /> TOTAL FUNDING REQUEST(add the two lines above) $ 1,066,377 <br /> Additional information about your project(please refer to the guidelines).This information is not scored.It is <br /> used to determine project readiness to proceed and other eligibility issues. <br /> Applicant requests consideration for partial loan forgiveness or a lower interest rate <br /> (see guidelines).You must provide median household income information for your <br /> service area, using either Census 2000 data or an independently conducted income <br /> survey(Contact Myra Baldini at 360.725.3152 if you need further information).This <br /> information must be included with your application to be considered. ❑YES E NO <br /> Applicant requests retroactive funding (see guidelines for eligibility requirements). ❑YES n NO <br /> DOH Form 331-201(Rev.10110) <br /> I <br />