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, . <br /> APPROVED <br /> Application Number ',:o / C. - . <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 11 A NIA_` Agent r IAA 1111.11 <br /> Address filES 1Teinti A1(' 2 'temitgAszrimist <br /> Telephone VIJI'' M"S AX1.i Lrft411 i .02. K10 . <br /> Location <br /> 1. Town Road Name 11 A 1.._ <br /> 2. Distance and direction iron nearest intersection Aig,a Aw' ` ti. I <br /> 3. Side of Town Road (circle one) NortTh South East t <br /> 4. Fire Number or Lot Number/Subdivision Name 1,1*a. 'a (_�Ii ` L ht /� <br /> 5. Location of new driveway is 100_feet�(/ire� one (��South East west <br /> - <br /> of nearest driveway. Fire Number "7 rf j' Lin <br /> 6. Location of new driveway is on(circle onApppositc 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 /> ---_4— Concrete <br /> Asphalt <br /> Gravel <br /> Other(explain) <br /> �., <br /> Culvert Size /5 Length 30 Type ee.Gt.,-4.47e.. esy,1/4_ <'..-cr,..e. ...a7/..-=. -- <br /> Not required (explain) c... ,q,•-„cd„r e.....60‘.........11/4...c..5 <br /> Applicant has completed the attached checklist and agrees to install the driveway in accordance <br /> with the pre vi ions of the check ist anr,.e Town of Roxbury Driveway Permit Ordinance <br /> Signed xft l 6 t1e <br /> Date L <br /> Approved by the Town of Roxbury Date CV/'I,/ �,t C- <br /> D/r-c.Al X/L4- / /.l 6 i9..!p /', I ,.i/4o e_ e ,q�,10 SfrirE"r7-T <br /> /Pc©t•i/2E b . /5."44 G .0/T <br /> �Yy 7 '-' c `"*AL. G.1otec: ` <br />