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srrE PLAN FOR PROPOSED DEVELOPMENT IN MARION COUNTY Block: / i Scale: /1'6o ' D~wn By: certify that the above information i$ accurate to the Ix:st of my Applicant (Plea~ Pr~t) ~:~t let/ MC: 1~-60 Rev, 11/91 Mailing Address: .... Applicant's Signamre: .~_,~ ~ -- FOR OFFICE USE ONLY PLANNI~qG: Date: PUBLIC WORKS: Date: B LrlJ..D ING INSPECTION: Date: / Range: / Phone: ~¢-7- ~c'/ Dat~;