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$�k <br /> Application Number /Q Ze"/7 -3 <br /> APPLICATION FOR DRIVEWAY/ACCESS PERMIT <br /> TOWN OF ROXBURY <br /> The undersigned hereby applies for a permit to construct a new driveway or modify or change <br /> the use of an existing driveway connected to a Town Road. <br /> Names: Owner Gn.l( 'E`e#51.' .' )))i T° Agent z-4)IGh�F/S� '�' t;G e77-e <br /> Address '75a5-- ;3 c9,- t.)/;:0C ?1 t<. 7 3 H wv <br /> ,C4/4 tit w- LS-3.S> 7 P J ,$ox 77.5 <br /> Telephone ?,3' /e/7 ' /°#/iva G gt N w, 6-3-5-?f <br /> fir' lam/ rJ °TT` 1° - �> - ti <br /> Location <br /> 1. Town Road Name %�'_ V HA W!< ,N� <br /> 2. Distance and direction from nearest '• -rsection ;5 ;���?'%,% ,' 1 ;SL,4'y <br /> 3. Side of Town Road (circle one) o South East West <br /> 4. Fire Number or Lot Number/Subdivision Name 2_07- <br /> 5. Location of new driveway is /0 feet(circle one) North South CS1 West <br /> of nearest driveway. Fire Number LOT 'v <br /> 6. Location of new driveway is on(circle one) same opposit)side as 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 /> 1C Concrete <br /> X Asphalt • <br /> Gravel <br /> Other(explain) <br /> Culvert Size /8 Length 3v Type Cri�.t,�4�► <br /> Not required(explain) #7,04, c - 5 <br /> Applicant has completed the attached checklist and agrees to install the driveway in accordance <br /> with the provisions of the checklist and the Town of Roxbury Driveway Permit Ordinance <br /> Signed I ` __ AI� i . )Le Date �7'- ,y_/'T <br /> Approved by the Town of Roxbury s� Date_ 8,37zo<-7 <br /> APPROVED <br /> Xiard vil p2 �✓���� <br />