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Please provide all information requested; an incomplete application may delay approval <br /> ❑ FACILITY INFORMATION I <br /> Name of Facility: S� Y u G g =00 <br /> Street Address: I 2.Z p <br /> City: C-, Zip Code: <br /> O'FORMER NAME OF FACILITY <br /> ❑,BUSINESS OWNER INFORMATION <br /> Business Owner Name: r <br /> Home Address: <br /> Mailing Address: () 0 S¢� <br /> Telephone Number: <br /> ❑ PROPERTY O . ER INFORMATION <br /> Property Owner Name: <br /> Home Address: <br /> Mailing Address: Q, Cf <br /> Telephone Number: a l6 — <br /> I] 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: <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 INFORMATIO <br /> List foods to be served and/or provide menu: <br /> ho ` <br /> ❑ OTE&TRAL NFO TION . . <br /> Anticipated Business Hours: Open: S7AM Close: <br /> Anticipated Number of Employees: <br /> EHE 16-01 4 PLAN CHECK GUIDE <br /> 8/01/16 <br />