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Application Number Z a 'G - <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 /> tni l-ez <br /> Names: Owner �ut} MG�.�ck,. � A�� �''L�gent � <br /> Address Los i3" Ave- <br /> 13ocab,w LJL, 339i$ <br /> Telephone we- ,i 2 Matt 40e 343-360 f <br /> (ooG 0-238 f q dA <br /> Location <br /> 1. Town Road Name f'1 y lrktw ic Lc <br /> 2. Distance and direction from nearest intersection a-am ciQ Leinsiey + Ryy k <br /> 3. Side of Town Road (circle one) ED South East West <br /> 4. Fire Number or Lot Number/Subdivision Name g1oskj je F,'d Lof- 4'2. <br /> 5. Location of new driveway is ZOO feet(circle one) North South 4 West <br /> of nearest driveway. Fire Number Lot- <br /> 6. Location of new driveway is on (circle one) opposite side as nearest driveway <br /> Proposed Access Use <br /> V j Residential,Number of dwelling units <br /> Commercial,Number of Parking Spaces <br /> Agricultural <br /> Other <br /> Construction Material <br /> X Concrete — b G h1- <br /> X Asphalt -- RTC►.'- - ta►� oac�, <br /> Gravel <br /> Other(explain) <br /> Culvert Size Length Type <br /> Not required (explain)_6-x-,-57-„44,- 4 4,7.-„1 C.c.-&-s_c , . ,- <br /> AIA •••, "-4 4-5 4!7i v-GO G� . X/ST••<IG .-4o.cc .a®�G N <br /> Applicant has completed the attached checklist and agrees to install the driveway in accordance 7° '4e-'r-1,�a <br /> with the provisions of the checklist and the Town of Roxbury Driveway Permit Ordinance "v° <br /> Signed 401eA, Dater/I/ l( <br /> Approved by the Town of Roxbury --�� _-w�,,,.��- Date /jii, <br /> APPROVED <br />