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O 0(01 cal - 1 ^7 <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 Mark leer^ Agent �`""�'�` ' <br /> Address Z 9 e1 tti 4 1.4^ f. <br /> rra Its t of ct rot 4.47 S-3s"7r <br /> Telephone Q- Y 3 8- 75-d/ <br /> Location <br /> 1. Town Road Name HD rnl r el 120( <br /> 2. Distance and direction from nearest intersection F;s),k. kt.led HO!'t " £Q S+ //R.r,t11C .3. Side of Town Road (circle one) North South teSk West <br /> 4. Fire Number or Lot Number/Subdivision Name t- i. <br /> 5. Location of new driveway is 6SA0 feet(circle one) ort South East West <br /> of nearest driveway. Fire Number S fo 3 C <br /> 6. Location of new driveway is on(circle one) same oppose e 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 /> X? Asphalt <br /> �( Gravel <br /> Other(explain) <br /> Culvert Size Length 3 0 Type Sferl <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 44/ £ -- Date T—/7—/‘ <br /> Approved by the Town of Roxbury // Date 3 1 V <br /> a4a 3 aYQ <br />