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Please provide all information requested; an incomplete application may delay approval <br />❑ FACILITY INFORMATION <br />Name of Facility: ` ue <br />Street Address: <br />City: L()�)\ <br />Zip Code: CjbZy <br />❑ FORMER NAME OF FACILITY <br />-V� * V \131\4V ?)aA ��t <br />❑ BUSINESS OWNER INFORMATION <br />Business Owner Name: V UA <br />Home Address:1 m b I r i <br />LOQ A OlS 2x-10 <br />Mailing Address: '1 1 \ O \ 0 <br />1 A C162LIC <br />Telephone Number: (20Q) ') ` - %j6,53 <br />❑ PROPERTY OWNER INFORMATION <br />Property Owner Name: tV <br />Y' <br />Home Address: C LN <br />L j A S2 kA <br />Mailing Address: 5 YWOQe LN. <br />LOP / t q 5290 <br />Telephone Number: 12 - WS j <br />❑ CONTRACTOR INFORMATION <br />Name of General Contractor: <br />Mailing Address: <br />Telephone Number: <br />Contact Person on Site: <br />Site Phone Number: <br />❑ UTILITIES <br />Source of Facility Water Supply: CM OF 10-91 <br />Backflow Protection: <br />System to be used for Liquid Waste Disposal (Sewage): <br />Solid Waste Disposal to be provided: <br />Grease Interceptor: <br />❑ FOOD INFORMATION <br />List food(s) to be served and/or provide menu: E m CAN <br />� tEi EAD ` <br />C) n 9 S 1 <br />❑ OPERATIONAL INFORMATION <br />Anticipated Business Hours: Open: <br />Close: 7 1CID R–El— <br />Anticipated Number of Employees: 11) <br />EHD 16-01 4 PLAN CHECK GUIDE <br />7/5/17 <br />