Laserfiche WebLink
Please provide all information requested; an incomplete application may delay approval <br /> FACILITY INFORMATION <br /> Name of Facility: S <br /> Street Address: w O <br /> City: Zip Code: <br /> ❑ FORMER NAME OF FACILITY <br /> BUSINESS OWNER INFORMATION <br /> Business Owner Name: <br /> Home Address: �� } 2 <br /> Mailing Address: ,1 <br /> Telephone Number. o 011 <br /> ❑ PROPERTY OWNER INFORMATION <br /> Property Owner Name: G <br /> Home Address: <br /> Mailing Address: G d,eo 2 �{ <br /> Telephone Number: ecU 5? 2 <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: } Fic <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 /> last food(s)to be served and/or provide menu: <br /> r <br /> ❑ OPERATIONAL INFORMATION <br /> Anticipated Business Hours: Open: l Close: <br /> Anticipated Number of Employees: <br /> EHD 1601 4 PLAN CHECK GUIDE <br /> 7/5/17 <br />