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From:TOWN OF ALBION 05/06/2015 10:58 #535 P.003/003 <br /> l <br /> . E <br /> i <br /> AKNOWLEDGEMENT: <br /> As owner of the above named property I agree to all terms,conditions,and specifications <br /> outlined in the above permit and in the Town of Albion's Driveway and Culverts Ordinance. I <br /> also acknowledge and agree that I am responsible for any damage to the roadway,shoulder or <br /> right-of-way,which occurs during the construction process,up to and including any time period i <br /> until an occupancy permit and/or final inspection notice from the Town of Albion Building <br /> i. <br /> Inspector is issued and received by the Town. I agree that the damage deposit of$1000.00 I <br /> make will be retained until the Town Board acts to release the deposit. Costs for any damage, f <br /> solely determined by the Town,will be deducted from the deposit prior to return. <br /> f. <br /> Property Owner Signature Date E <br /> Approval of initial access t,1111:)— 5-S--/ <br /> Town Representative Date <br /> E <br /> Additional Access: i <br /> Access granted/denied by the Town Board on: ,20 <br /> Reason for denial <br /> a <br /> i <br /> Deposit amount: Type: personal check <br /> money order/cashier's check <br /> Date deposit authorized to be returned by: Public Works Staff: k <br /> Town Board: <br /> Date deposit authorized to be held by Town Board: t <br /> Date deposit returned by Clerk/Treasurer: <br /> Comments: l i <br /> 1 <br /> f <br /> E <br /> f <br /> a <br /> s <br /> t <br /> i <br /> (k <br /> 3 <br /> 1 <br /> i <br /> I <br /> t <br /> 1 <br /> I <br /> F <br /> C:\Users1Albion\Documents\DRIVEWAY APPLICATION&PERMTF.docx 3 <br /> 4124046 1 <br /> I <br /> i <br /> 1 <br /> 1 <br />