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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 <br /> until an occupancy permit and/or final inspection notice from the Town of Albion Building <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, <br /> solely determined by the Town,will be deducted from the deposit prior to return. <br /> Property Owner Signature Date <br /> Approval of initial access \171:0- 6- 5-1 1 <br /> Town Representative Date <br /> Additional Access: <br /> Access granted/denied by the Town Board on: ,20 <br /> Reason for denial <br /> Deposit amount: Type: personal check <br /> money order/cashier's check <br /> Date deposit authorized to be returned by: Public Works Staff <br /> Town Board: <br /> Date deposit authorized to be held by Town Board: <br /> Date deposit returned by Clerk/Treasurer: <br /> Comments: <br /> • <br /> C:\Users\AlbionDDocuments\DRIVEWAY APPLICATION&PERMIT.docx 3 <br /> 4/24/06 <br />