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Please provide all information requested; an incomplete application may delay approval <br /> { ;INFORMATION <br /> Name of Facility: <br /> Street Address: <br /> City: Zip Code: (,, <br /> "'*,1;: . M'E O FACILITY <br /> C3 �[X3UVEtBs OWNER INFORMATION f` <br /> Business Owner Name: L r�c <br /> Home Address: I VOl" CA- <br /> Mailing Address: <br /> Telephone Number: - IS-44 PLE <br /> EI1`Y QWNER INFORMATION <br /> Property Owner Name: 'De>\1 Cp�Er <br /> Home Address: <br /> Mailing Address: 1'7 G. <br /> Telephone Number: • ' _ _ <br /> CT,OR INFORMATION <br /> Name of General Contractor: sg d <br /> Mailing Address: �t 4515 <br /> Telephone Number: <br /> Contact Person on Site: <br /> Site Phone Number: 7�01 _ t3 I q_ (PI 9 <br /> rQ r��tE$ <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 /> PO' ItlV .RMATION <br /> List food(s) to be served and/or provide menu: <br /> 1-1 VE d i L L5 (A I G _ SAM P a=, s <br /> ,C9 C3PEAA'119NAL INFORMATION <br /> Anticipated Business Hours: Open: Close: <br /> Anticipated Number of Employees: <br /> EHD 16-01 4 PLAN CHECK GUIDE <br /> 715117 <br />