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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 A iae_trg' �12EX1 Lr Agent —__-- <br /> Address �l tRA Agent — -- — _ <br /> 114 q D r J at .S_37/� -- --- - <br /> Telephone <br /> Location <br /> 1. Town Road Name a go <br /> 2. Distance and direction from nearest intersection 2 k' n <br /> 3. Side of Town Road (circle one) North South East Wes2 ,�,r - `'u'M�'J <br /> 4. Fire Number or Lot Number/Subdivision Name 7 (4, ? <br /> 5. Location of new driveway is 75_ feet (circle one) North , utl East West <br /> of nearest driveway. Fire Number <br /> 6. Location of new driveway is on (circle one) 411110 opposite 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 <br /> _ Asphalt <br /> Gravel <br /> — Other (explain) <br /> Culvert Size Length Type <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 ,d the Town of Roxbury Driveway Permit Ordinance <br /> Signed <br /> _Or <br /> ,. Date <br /> Approved by the. Town of Roxbury _ ------ ----- <br /> llatc /e0- �� <br />