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Please provide all information requested; an incomplete application may delay approval <br /> Name of Facility: /'{/1Q, C� (� <br /> Street Address: W <br /> City: ,� Zip Code:IlS ?,.L©^ <br /> ❑ FORMER NAME OF FACILITY <br /> L IJ C 'L. I CLl 1 7L�. <br /> ❑ BUSINESS OWNER INFORMATIO <br /> Business Owner Name: =82VTo d <br /> Home Address: , <br /> Mailing Address: <br /> Telephone Number: — <br /> ❑ PROPERTY OWNE <br /> Property Owner Name: <br /> Home Address: 9-p f <br /> Mailing Address: t <br /> Telephone Number: ard_ <br /> ❑ CONTRACTOR INFORMATION <br /> MEL- <br /> Name of General Contractor: 1� �) o �✓1 l rn 2U—✓'i h <br /> Mailing Address: t A 6 S t eg ,q 1. CA- 9S_&7S <br /> Telephone Number: el( I. 3 - v im <br /> Contact Person on Site: 7o AA- Fro-b" <br /> Site Phone Number: <br /> ❑ UTILITIES <br /> Source of Facility Water Supply: S*70 1::� ' k�) - <br /> Backflow Protection: -ie\6(S I <br /> System to be used for Liquid Waste Disposal (Sewage): x,l <br /> Solid Waste Disposal to be provided: Y016 <br /> Grease Interceptor: Y61S b 6e q:L' <br /> ❑ FOOD INFORMATION <br /> List food(s) to be served and/or provide menu: <br /> ❑ OPERATIONAL INFORMATION <br /> Anticipated Business Hours: Open: Close: <br /> Anticipated Number of Employees: <br /> EHD 16-01 4 PLAN CHECK GUIDE <br /> 7/5/17 <br />