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Application Number ' r f <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 T,'�;�I�LI 1f'S5 ;4& cnt <br /> Address c1 r_ S •_ <br /> lL v � <br /> ��t �c.-Ccc , ��S 3-351C <br /> Telephone �{j' -- 1-N4-705 Li <br /> Location 11 <br /> 1. Town Road Name _ A.Slt`� 1 <br /> 2. Distance and direction from nearest intersection l b•c•(..- <br /> . w ' ii 4e <br /> 3. Side of Town Road(circle one) North South (TM West r <br /> 4. Fire Number or Lot Nuntber/S bdivision Name 1• 3/ ?Awl_ t'ft�j <br /> 5. Location of new driveway is J d 0 feet(circle one) No tt' South * West <br /> of nearest driveway.Fire Number "i ZoZ F(4��o 6. Location of new driveway is on(circle one) same Vpositc sid nearest driveway <br /> Proposed Access Use <br /> Residential,Number of dwelling units <br /> Commercial,Number of Parking Spaces <br /> Agricultural <br /> Other <br /> Construction Material <br /> Concrete <br /> v' Asphalt <br /> Gravel <br /> Other(explain) <br /> Culvert Sire .45- Length 24 i .I ypc V\) " �JLoa IL <br /> Not required(explain) 3 c ' <br /> Applicantthas completed the attached checklist and agrees to install the driveway in accordance <br /> with t ovi.i1 j s 4 e checklist and the Town of Roxbury Driveway Permit Ordinance <br /> Signed I11 f £ '"`�' ' I Date <br /> Approved by the Town of Roxbury .' }� . Date j /LC/ <br /> 7 <br />