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Application Number CK / 5-' -' <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 driv way connected to a Town Road. <br /> Names: Owner Agent R-1/1 14eirr).1 (Jr <br /> Address Ok? 5.!/c-ea .'G!. i^:`.(.sj'•i <br /> c,,< .. t v'+ t�'/) ai <br /> Telephone 4,e- G t111 - 3 It <br /> Location 7 <br /> 1. Town Road Name 1"�I ti I,1(, Lt v ('. '� <br /> 2. Distance and direction from nearest intersection (.6: (-e (\ l.1 W1a v( ( �� �(r�' Lc�nL.- <br /> 3. Side of Town Road(circle one) North South West <br /> 4. -Fire-Num�or Lot Number/Subdivision Name Z~�r tk'Lc l v ��w �: fi\ta��,. ; `ct <br /> 5. Location of new driveway is I cc feet(circle one) North (old ' East West <br /> of nearest driveway. Fire Number 72 .'i <br /> 6. Location of new driveway is on(circle one) same posits"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 - F%n:;� �' ' lv if 1'4'1/31 (P-V1e <br /> Gravel <br /> Other(explain) <br /> Culvert Size /.? Length 3, `' Type c'. , �:� �..r ,-� <br /> Not required(explain) c <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 Date I Z-Z2-1 S <br /> Approved by the Town of Roxbury Date / / /<z S <br /> APPROVED <br />