APPENDIX 3
TOWN OF SHALLOTTE
APPLICATION FOR SEWER TRANSMISSION/WATER DISTRIBUTION LINE REIMBURSEMENT
   (Please print or type)
The undersigned hereby applies for a Sewer Transmission/Water Distribution Line Reimbursement with the Town of Shallotte. The Sewer Transmission/Water Distribution Line Reimbursement is for the construction of an approved sewer transmission/water distribution line to serve the subject project. The collection/transmission/distribution line(s) must be designated on the Master Wastewater/Water Plan or approved by the Public Works Director during plan approval. The following information is required prior to processing the reimbursement request.
Size of transmission line installed: _________________________________________________________________
Size of utility required to serve project: ____________________________________________________________
Project:  _____________________________________________________________________________________
Location: ____________________________________________________________________________________
Date of Town Approval of Project: ________________________________________________________________
Developer/Owner:  __________________________________________________________________________
               (Name of Person designated to receive reimbursement payment)
Company Name, Address*: ____________________________________________________________________
City, State, Zip: _____________________________________________________________________________
Phone Number:  (    ) _________________________  Fax Number (  ) _______________________________
Has the project been publicly bid in accordance with North Carolina G.S. § 143-129 or G.S. § 143-131? Yes/No
If no, when do you anticipate accepting public bids?  _______________________________________________
Project Consultant/Engineer:  __________________________________________________________________
Contact Person Phone Number: (    )  ____________________________________________________________
*Note:   This address will be used for all correspondence and payments. It is the responsibility of the owner to notify the Town of Shallotte of any changes.
The following information must be submitted with this application in order to receive approval of this reimbursement. If the answer to any of the following questions is “NO,” the request is incomplete and will not be processed.
   1.   Has the project been accepted for maintenance by the Town of Shallotte? ________
   2.   Has an estimate of eligible reimbursable costs with linear footage of utility, number of valves and linear footage of bore and jack, signed and sealed by a professional engineer registered in the State of North Carolina been submitted with this application?  ________
   3.   Has documentation of public bid including certified bid tab statement by a professional engineer or architect registered in the State of North Carolina been submitted with this application? ________
   4.   Has a copy of the executed contract between the Developer and the selected contractor been submitted with this application?  ________
   5.   Has a Certified Sales Tax Statement from the contractor for the materials used as a part of the reimbursement been submitted with this application?  ________
   6.   Has a copy of the final payment to the contractor, including final invoice, been submitted with this application? ________
   7.   Has  a copy of acceptance/approval  by  NCDENR  been  submitted with this application?  ________
I acknowledge that the above information is accurate.  I also recognize that, dependent upon the amount of the reimbursement request as well as the number of other reimbursement requests received by the Town of Shallotte during the fiscal year, the reimbursement shall be paid over multiple years up to a maximum of six (6) years and may NOT fully reimburse the applicant for all construction costs.
By: ___________________________________________________________________
      (Print Name)
Signature: ______________________________________________________________
      (Developer/Owner)
Date: __________________________________________________________________
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   TOWN OF SHALLOTTE STAFF USE ONLY
Approved by: ____________________________________________________________
Date: ___________________________________________________________________
Comments:
(Ord. 07-38, passed 11-6-2007)