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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 k,j;kt s Y,at,0N L� . Agent e;t. <br /> Address 4.0%, 3$3y E Rei orzi-cree.4, •J\ <br /> c315y <br /> Telephone 'Mpy -11.7.-01S0, (4Yi) SS-t3$6 <br /> Location <br /> 1. Town Road Name f t eras 'ku c <br /> 2. Distance and direction from nearest intersection I.4a" <br /> 3. Side of Town Road(circle one) North South East West <br /> 4. Fire Number or Lot Number/Subdivision Name lap(.1. -.- E.4§44. <br /> 5. Location of new driveway is 4teet(circle one) North South • East West <br /> of nearest driveway.Fire Number ipo&i <br /> 6. Location of new driveway is on(circle one) same • e ide 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 /> Concrete <br /> Asphalt <br /> Gravel <br /> Other(explain) <br /> Calvert Size tV Length Se` Type Gw1�.r;LA Co r F t W d,115 <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 and the Town of Roxbury Driveway Permit Ordinance <br /> Signed Date /Z-if-i <br /> Approved by the Town of Roxbury � --.,�� Date <br />