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Please provide all information requested; an incomplete application may delay approval <br /> ❑ FACILITY INFORMATION <br /> Name of Facility: <br /> Street Address: Z" <br /> City: Zip Code: <br /> ❑ FORMER NAME OF FACILITY <br /> ❑ BUSINESS OWNER INFORMATION <br /> Business Owner Name: Rb re :>Av1 1,4 <br /> Home Address: 04444 <br /> Mailing Address: <br /> Telephone Number: <br /> ❑ PROPERTY OWNER INFORMATION <br /> Property Owner Name: <br /> Home Address: <br /> Mailing Address: <br /> Telephone Number: <br /> ❑ CONTRACTOR INFORMATION <br /> Name of General Contractor: CbDP1 <br /> Mailing Address:4�j 0Y njY{, G ,;a CVA yytVItp 61594 1 <br /> Telephone Number: CARO ) <br /> Contact Person on Site: RR CV-- <br /> Site <br /> VSite Phone Number: q 1 la -11,111'j- 000o <br /> ❑ UTILITIES <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 /> Grease Interceptor: <br /> ❑ FOOD INFORMATION <br /> List food(s) to be served and/or provide menu: 44 <br /> ❑ OPERATIONAL INFORMATION <br /> Anticipated Business Hours: Open: Close: <br /> Anticipated Number of Employees: <br /> EHD 16-01 4 PLAN CHECK GUIDE <br /> 12-27-2011 <br />