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Application Number r <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 ►, l M Agent t ,1,1 `]V.i►;s .r <br /> Address . • +,1 r In, ,l!1 t • <br /> A . <br /> Telephone °�_ ,. �. <br /> Location <br /> I. Town Road Name , •1 <br /> 2. Distance and direction fro nearest intersection 10 •• <br /> 3, Side of Town Road(circle one) North South MI) Wes <br /> 4. Fire Number or Lot Number/Subdivisi � Name it, s, �, WO. h. ' ifittS <br /> S. Location of new driveway is s7,2„ fee (circle m o 1 South East West <br /> of nearest driveway. Fire Number b , ��; , <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 <br /> Commercial,Number of Parking Spaces <br /> Agricultural <br /> Other <br /> Construction Material <br /> Concrete <br /> Asphalt <br /> Gravel <br /> Other(explain) <br /> Culvert <br /> Size , b Mia. Type Y @ <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 /> L-_4-1:1 1..-1. <br /> Signed g - Hatt <br /> Approved by the Town of Roxbury £,,`1 `x -- } <br /> APPROVED <br />