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Application Number <br /> APPLICATION FOR DRIVEWAY/ACCESS PERMIT <br /> TOWN OF ROXBURY <br /> The undersigned hereby applies for a permit to construct a new driveway or modify or change <br /> the use of an existing driveway connected to a Town Road. <br /> Names: Ownertgy IC Agent <br /> Address \Ok 2"'° S� <br /> �l fs�J atc_o+re.A.JS, .) <br /> Telephone 6,08-21°1-SO4g <br /> Location <br /> 1. Town Road Name L i.Lr -i RD <br /> 2. Distance and direction from nearest intersection <br /> 3. Side of Town Road (circle one) North Sout as West <br /> 4. Fire Number or Lot Number/Subdivision Name ••• DL{ <br /> 5. Location of new driveway is feet (circle one) ort1' South East (SaD <br /> of nearest driveway. Fire Number ° '-t 8 <br /> 6. Location of new driveway is on (circle one) samepposite side as nearest driveway <br /> Proposed Access Use <br /> Residential, Number of dwelling units <br /> Commercial, Number of Parking Spaces <br /> Agricultural <br /> Other <br /> Construction Material <br /> Concrete <br /> Asphalt <br /> Gravel <br /> Other (explain) <br /> Culvert Size Length Type <br /> Not required (explain)X <br /> Applicant has completed the attached checklist and agrees to install the driveway in accordance <br /> with the provis'ons of the ecklist and th own of Roxbury Driveway Permit Ordinance <br /> Signed Date 6 d <br /> Approved by the Town of Roxbury Dates 0 -7,‘ <br /> 2_5 277 CO <br /> k/INI\R <br />