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• ti's <br /> el y p Y Y royal <br /> P}i�ase provide all informs ion requested; an incomplete.a plication may dela app <br /> ❑ FACILITY INFORMATION <br /> s <br /> Name of Facility: 1;,�E,jOQAN�� 1D;PrS <br /> Street Address: 431. C Lob) ME, <br /> City: L A zip Code: R�z4t) <br /> 1:1FORMER NAME OF,FACILfIT,Y <br /> ❑ BUSINESS OWNER INFORMATION <br /> Business Owner Name: . R t- V <br /> OD �L Qt7P6c16 LJA au <br /> Home Address: d N LG-J(-0'- CT r <br /> Mailing Address: G r 14 1 t� L4 i., A Lk� <br /> Telephone Number: . 40-$la'l 6 5i� � r✓ � 3� � -b3. <br /> ❑ PROPERTY OWNER INF. . <br /> O;RMATION::. <br /> Property Owner Name: LDD <br /> u 090 P, P, 14,Ott If p <br />'I Home Address: <br /> t Mailing Address: <br /> Telephone Number: 3 Q <br /> ❑ CONTRACTOR INFORMATION <br /> Name of General Contractor: <br /> E 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 /> be to Disposal Solid Waste Dis provided.- <br /> p <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: S-'UD A Close: <br />'I <br /> Anticipated Number of Employees: LA ow F <br /> I <br /> I <br /> EHD 16-01 4 PLAN CHECK GUIDE <br /> 11-7-07 <br />