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srrE PLAN FOR PROPOSED DEVELOPMENT IN MARION COUNTY <br /> Zone: ~ Map: <br /> <br />Situs Address: /fj~.~O.,/') ffJ,4'E77L/ ],_/lot/g- A./~c' <br /> <br />Block:__ Subdivision: <br /> <br />LOE <br /> <br />DAT~: <br /> <br />MC: 15-60 <br />Rev. 11/91 <br /> <br />I certify that the above information i~ accurate to the best of my knowledgb7 <br />Applicam 0Olease Prin0 ~,.¢R~/ 7Jo,,,n,lx.~vrv' Phone: <br /> <br /> .,, <br />Applicm'a $ Signatm-e: ,, Date: <br /> <br /> FOR OFFICE USE ONLY <br />PLAN1XrI2NG: Date: <br />PLrBLIC WORKS: Date: <br />BUILDING INSPECTION: Date: <br /> <br /> <br />