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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: Owner;.5.1.e.„<„,1,4 'n - C Agent <br /> Address J(' ,r <br /> Telephone (9d y- 3 -36 7o <br /> Location C M 135'60 <br /> 1. Town Road Name „g ' 6/ 4 / . j - <br /> 2. Distance and direction from nearest intersection �,.,,� J��5o A'\ o.( wy L• <br /> 3. Side of Town Road (circle one) North South East est <br /> 4. Fire Number or Lot Numb9r/��b ivision Name <br /> 5. Location of new driveway ii feet (circle onek7cTit South East West <br /> of nearest driveway. Fire Numb (Q(a(0 <br /> 6. Location of new driveway is on circle one) s me)opposite 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 if Length 3 z Type •=+-(• S <br /> Not required (explain) <br /> Applicant has completed the attached checklist and agrees to install the driveway in accordance <br /> with the provisions of the checkl., :.-• le Town of Roxbury Driveway Permit Ordinance <br /> // <br /> - Date o?? - <br /> ' u1�{ <br /> Approved by the Town of Roxbury 1A-4-g-) Date <br /> / ' / ) d 51- t <br />