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AKNOW LEDGEMENT: <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$2500.00 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 /> & . .. a. / • tdi, r1 .1 ` ''' 1 34 koito <br /> ropert !Owner Signature p � Da e <br /> Approval of initial access <br /> Town Representative Date <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 /> C:Users`Aibion%Documents DRIVEWAYAPPL(CAT[ON R RMIT 1-1-201b.docx 4 <br /> 4,24:06 <br />