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4 <br /> App:ication Number 04)/6 '',.,Y <br /> APPLICATION FOR DRIVEWAY/ACCESS PERMIT <br /> TOWN OF ROXI3URY <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 /> I' , <br /> Names:Owner Dkt “-A. l (,c.,,,n.VII Agent /kL , ,A{c <br /> Address 2u:i.• +1.•�,I•e-SJi•e f C i.r;,- 2. a> , n.., <br /> � 1,� , �- = ' �'- � :%bi S',},.��•.l .)r.���,. .?ice. <br /> Telephone tZ•t,•. /.,;: Cs, :!.� . <br /> Location 4 0.4ve y57 <br /> 1. Town Road Name evlyiy Lthd Lave <br /> 2. Distance and direction from nearest intersection Zoo' -,E s L,yt ,jcy LA <br /> 3. Side of Town Road(circle one) North CSbutii• East West <br /> 4. Fire Number or Lot Number/Subdivision Name .>�; 3 / <br /> 5. Location of new driveway is WI) feet(circle one) North South East Zest <br /> of nearest driveway.Fire Number c3,-1 _ <br /> 6. Location of new driveway is on(circle one) same pposite side as nearest driveway <br /> Proposed Access Use <br /> 1 Residential,Number of dwelling units <br /> Commercial,Number of Parking Spaces <br /> Agricultural <br /> Other <br /> Construction Material <br /> _ Concrete. ,- L`� <br /> X Asphalt �`„ <br /> _y2_— Gravel <br /> Other(explain) <br /> Culvert Size I 6 Length jr, ' Type_ 4_,2i91e..•r_. .71. c, �4Gl� <br /> Not required(explain) 1 <br /> /114$Gv._d <br /> Applicant has completed the attached checklist and agrees to install the driveway in accordance '''`rO"''.4`-4 <br /> with the provisions of the checklist and the Town of Roxbury Driveway Permit Ordinance r <br /> Signed `�----� <br /> Date ..5-- I (.,- ( L. <br /> Approved by the Town of Roxbury G Date 0,,/,?_,,, G <br /> • <br /> APPROVED <br /> .. <br />