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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$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 /> — 3— a -- <br /> Property Owner Signature Date <br /> Approval of initial access , � 3"a`Z0� <br /> own Repr entative 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\Albion\Documents\Driveways\DRNEWAY APPLICATION&PERMIT 1-1-2016.docx 4 <br /> 4/24/06 <br />