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• <br /> 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 Q64,/,/, Ruiz /t,✓o Agent / e,vseA. &' /dtor Z . <br /> Address 905- AlA Isis s,v S7 v.vrit //o 84 ru,tt 4' <br /> S�u k d r 1-y , S3 4-6'3 etlAvivolroi wz. sri s"9 7 <br /> Telephone 6o1- 370- .2 t 77 oag- P' m'- 4s71e <br /> Location <br /> 1, Town Road Name 0/A S/in A// Th.g /7 <br /> 2. Distance and direction from nearest intersectio 1 ! -Cr G v Q0 L <pQsj PQ <br /> 3. Side of Town Road (circle one) North outh West <br /> 4. Fire Number or Lot Number/Subdivision Name 1'5/oc .!a e- <br /> 5, Location of new driveway is Ai' feet(circle one) li South CSID West <br /> of nearest driveway. Fire Number q yd 7 <br /> 6. Location of new driveway is on (circle one) ..ame 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 /> X Concrete <br /> Asphalt <br /> Gravel <br /> Other(explain) <br /> Culvert Size /1`' Length -3 ^3U Type Ae/n,a <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 checklist and the Town of Roxbury Driveway Permit Ordinance <br /> Signed rh44.72,411 Date <br /> Approved by the Town of Roxbury `�'`-'� Date 7 - r <br />