Owner/Applicant Information:
Name ____________________________________________________________
Street or Road & Number ____________________________________________
City or Town ___________________________ Zip _______________________
Telephone _________________________

The local road name ___________________________ about ______________ft.
(North) (South) (East) (West) from _____________________________________
(circle appropriate direction) (point of reference)
for the following purpose:

RESIDENTIAL ____ COMMERCIAL ____ DEVELOPMENT ____ OTHER ____

Description ________________________________________________________

The following information is information in regard to the location and requested entrance:

1. Number of entrances requested __________________
2. Proposed width of entrance(s) ___________________
3. Setback from center of road _____________________
4. The surface of proposed driveway is to be _________________________
5. Construction desired to commence on ______________, 20____ and be completed on _______________, 20 ____
6. Is this entrance part of a project/development requiring a D.E.P. permit or Town of Woolwich Subdivision approval? Yes ____ No ____

THE OWNER/APPLICANT HEREBY AGREES:

(1) To provide, erect and maintain all necessary barricades, lights, warning signs and other devices to safeguard traffic properly while the work is in progress.
(2) That the roadway will at no time be closed to traffic.
(3) Shall obtain and have delivered to the site any culverts and/or drainage structures which may be necessary for proper drainage.

FURTHER CONDITION OF THE APPLICATION: shall be that the owner/applicant shall well and truly pay all damages, fines and penalties for which he shall become liable and shall indemnify and save harmless said Town of Woolwich against all suits, claims, damages and proceedings of every kind arising out of the construction and maintenance of said driveway approach, including snow removal.

* Please draw a sketch in space provided below. Show description from town line, intersection or other identifying landmark.

__________________________________ _____________________
OWNER/APPLICANT SIGNATURE DATE

__________________________________ _____________________
ROAD COMMISSIONER OR DESIGNEE DATE

ROAD COMMISSIONER'S COMMENTS:___________________________________

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