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Application Number L® /(•' 4 <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 \ � �4` kJ k �`J t' 1 Agent i/� Je' �,-rte .,0 <br /> Address l .]tm��Q$ <br /> l.G.0✓ c� „ 5—” <br /> Telephone / a - l a 1 5 <br /> Location <br /> 1. Town Road Name , /14A., )k <br /> /4 s -t <br /> 2. Distance and direction from nearest intersection <br /> 3. Side of Town Road(circle one) North South East . W94 <br /> 4. Fire Number or Lot Number/Subdivision Name Lty <br /> 5. Location of new driveway is feet(circle one) North South East West <br /> of nearest driveway.Fire Number <br /> 6. Location of new driveway is on(circle one) same opposite side as nearest driveway <br /> Proposed Access Use <br /> Residential,Number of dwelling units / /4 o <br /> Commercial,Number of Parking Spaces <br /> Agricultural <br /> Other <br /> Construction Material � S+4244 <br /> Concrete 0,,,,� /v-e 62-4t Asphalt <br /> Gravel <br /> Other(explain) <br /> Culvert Size 18 if Length 3o Type c'044,dG4 .:. 'r'fnoc tlow��<ec.�.4 cc. <br /> Not required(explain) $ <br /> Applicant -• - leted th attac -• checklist and agrees to install the driveway in accordance <br /> with the p isions .f the c I- kF` and the own of Roxbury Driveway Permit Ordinance <br /> Date <br /> Signed /► �� /�/6 <br /> Approved by the Town of Roxbury Date /� j/ tyy <br /> APPROVED <br />