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Fees: <br /> Off-Premise ....................... $100 PIN# D - i 1—' ���0-3-OM—0 L �j� <br /> On-Premise ....... $ 50 <br /> Commercial Directional ... $ 25 <br /> BURNETT COUNTY SIGN PEI8IO <br /> MPUTEWSCANNED <br /> Applicant: y I G­T-O(Z <br /> Address: .s`T1�T C- tZ I 5 <br /> Phone#: [�' c� `f <br /> Property Owner: z cy-A l Vk�,\ P TZ L <br /> Address: R 0 , a&y- ;;�6 s <br /> Sin Type and Location Information <br /> Type: Off Premise ❑ On Premise K Directional ❑ LOT- i 0Sn1 l/ .-3 � l° <br /> Town � �SS Section GL or �-W 1/4 1/4 Property Zoning -" I <br /> Highway Road Name 5 (-A- � Highway/Road Side N ❑ S ❑ E 9 W ❑ <br /> Distance from Highway/Road Right-Of-Way �JS feet <br /> Distance between sign location and nearest road intersection is feet. <br /> Distance between sign location and centerline of road/highway is feet. <br /> Distance from nearest existing off premise sign(off premise sign applicants only) feet <br /> Number of existing free standing signs (on-premise only) <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my <br /> knowledge and belief it is true,correct and complete. I acknowledge that I am responsible for the detail and accuracy of all <br /> informaiton contained in this application(including any accompanying schedule)and I further declare that I recognize that <br /> this information I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a <br /> permit. I further accept all liability which may be a result of the County of Burnett relying on this information I am providing <br /> in this application. I agree to permit county officials charged with administering county ordinances or other authorized <br /> person to have access to the ab ribed pr mises any reasonable time for the purpose of inspection. <br /> Signature Applicant: <br /> Property Owner: <br /> R <br /> Sign Information Required MERSE <br /> Provide sketch illustrating the size(by dimensions), shape and message of sign. MAR 112015 <br /> Provide site plan drawing detailing location and positioning on property with referenced diBIJ4 EV6 NTy <br /> lines,road intersections,road right-of-ways anal existing signs. ZONING <br /> APPROVED BY: DATE: <br />