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Application Number Zv < <- — S <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 ,SC-err Cfi4st./74,, ? 'CA, \gent C,'`<<} Z r7,11.) .-ST C: <br /> 17 f, . <br /> Address 6 c, Z c T'N S7 . fl,"f > (v.*: y k-'K'L S !'/4 , <br /> L?.iL' rf �A.f-i4c s7 ti c ,, •' , z N'J:_ H �/'?i <br /> Telephone 6.t 't - r yr- S-SI y C3 s 7Z - 7 7 - 377y <br /> Location <br /> 1. Town Road Name Ft y x-14 w t( Z A NE <br /> 2. Distance and direction from nearest intersection 2.,c'c• F7 r A r ru L,UVyLi GejNE <br /> 3. Side of Town Road(circle one) North Fast West <br /> 4. Fire Number or Lot Number/Subdivision Name e er Z c) A'e,Gc k-1.74•4,.,,4' F/Laos <br /> 5. Location of new driveway is S^C. r feet (circle one) North South West <br /> of nearest driveway. Fire Number <br /> 6. Location of new driveway is on (circle one)( same 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 /> -K Concrete <br /> Asphalt <br /> Gravel <br /> _ Other(explain) <br /> Culvert Siie /8 Length 30 type _/re 1-4Na 1'1EG ‘,./4,44.1.4-9,4C <br /> Not required (explain)_ <br /> Applicant has completed the attached checklist and agrees to install the driveway in accordance <br /> with the provisions of tlheeklist and the Town of Roxbury Driveway Permit Ordinance <br /> Signed t, ,i --Ire /_-f f`,�� (7)t.�c ��C Date 7/- 2-/lr <br /> Approved by the'Town of Roxbury /j .•e.-----` Date /eZ d/C.; <br /> APPROVED <br />