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t_ <br />t .r 'Please provide all information requested; an incomplete application may delay approval <br />[3FACILITY INFORMATION <br />Name of Facility: LCasA <br />Street Address: <br />City: c <br />_. <br />w <br />Zip Code: <br />C1 FAFFIYLORMER[ME _._ <br />_. <br />❑ BUSINESSOWNER INFORMATION' <br />Business Owner Name: <br />Home Address: E Q <br />i <br />Mailing Address: <br />Telephone Numbe <br />❑ PROPERTY DWNERINFORMATION <br />Property Owner Name: <br />Home Address: <br />Mailing Address: <br />Telephone Number: <br />CONTRA NFO�i�ilA`'l'l - <br />.. <br />Name of General Contractor: <br />Mailing Address: Y, •— <br />p C� <br />Telephone Number: <br />Contact Person on Site: <br />Site Phone Number: <br />❑ UTILITIES .- <br />�__�_..._ _� <br />IM <br />Source of Facility Water Supply: <br />Backflow Protection: <br />System to be used for Liquid Waste Disposal (Sewage): <br />Solid Waste Disposal to be provided: <br />�T <br />Grease Interceptor:' <br />❑_FOOD INFORMATION <br />List food(s) to be served and/or provide menu: <br />❑ OPERATIONAL INFORMATION_"',. <br />Anticipated Business Hours: Open: <br />Close: <br />Anticipated Number of Employees: <br />�A y. <br />EHD 15-01 �. <br />8101!16 _ <br />PLAN CHECK GUIDE <br />