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3. In the event a culvert is required, said culvert shall be covered by sufficient material to protect it <br /> from the weight of vehicles using the access. <br /> 4. Placement and maintenance of culvert is the responsibility of the property owner. <br /> 5. All dimensions and construction of accesses will adhere to Dane County and Town of Pleasant <br /> Springs standards. <br /> 6. Nothing may be placed in the public right-of way except legally constructed mailboxes. <br /> 7. The Property owner is responsible for damage to road edge caused by demolition and/or 4 <br /> construction. <br /> I <br /> **Once the project is completed please contact(office staff will indicate appropriate contact <br /> below): <br /> XNSteve Kittelson at 608-445-9715 for inspection and issuance of occupancy permit. <br /> I <br /> The Public Works Department at 608-205-9169 for completion certificate. <br /> p <br /> ACKNOWLEDGEMENT: . # <br /> As owner of the above named property, I acknowledge and agree that I am responsible for any 1 <br /> damage to the roadway, shoulder, or right-of-way that occurs during the demolition and/or <br /> construction process, up to and including such time as an occupancy permit and/or completion t <br /> certificate from the TOPS Building Inspector or Public Works Staff is issued and received by the ) <br /> Clerk. I agree that the damage deposit of$ I make will be deposited and retained by the <br /> town until the Town Board acts to release the deposit. Costs for any damage; determined solely by <br /> the Town Board, will be deducted from the deposit prior to return. I understand that no deposit will be <br /> returned until: <br /> a. An Occupancy Permit has been issued by the Town of Pleasant Springs Building Inspector, I <br /> or <br /> b. A Completion Certificate has been issued by the Public Works Staff, and <br /> c. The Town Board acts to approve the release of all, or a portion of, the deposit and requests E <br /> a check to be issued to the property owner. <br /> s.,("4P4 <br /> Property Owner Si ture s <br /> Date C <br /> Approval of initial access 3 — -17 t t <br /> Town Representative Date <br /> Date deposit authorized to be held by Town Board: <br /> Date deposit authorized to be returned by: Public Works Staff: 1 <br /> Town Board: 1 <br /> Date deposit returned by Clerk/Treasurer: <br /> Additional Access: <br /> Access granted/denied by the Town Board on: 20 <br /> Reason for Denial <br /> a <br /> 4 <br /> Revised 05/24/12 v <br /> Z:SVJord files SROADS1Documents5acccsspermit updated 2012.doc <br /> 1 <br />