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Please provide all information requested; an incomplete application may delay approval <br /> ❑ FACILITY INFORMATION <br /> Name of Facility: S H I-_%�03�1 `S <br /> Street Address: Lf 6 7 N W L m vel. 1 3 <br /> City: t4 keo N Zip Code: <br /> ❑ FORMER NAME OF FACILITY <br /> I +3 S ;� (A0r?. we-aa l� <br /> • BUSINESS OWNERINFORMATION <br /> Business Owner Name: A V_c,0,je_ �} U <br /> Home Address: I (S S —14 StfA- Pit P0 t4 <br /> Mailing Address: SAM e <br /> Telephone Number: (,<01- ct _ S g`1 <br /> ❑ PROPERTY OWNER INFORMATION <br /> G'IZ FyCF,kb A, P 7 Ne�S <br /> PropertyOwner Name: <br /> Home Address: <br /> Mailing Address: 1 012, ll +''� S7, `1 4Ar j t7�DtS7a 9S3 P J <br /> Telephone Number: Zoe - H SZ <br /> ❑ CONTRACTOR INFORMATION <br /> Name of General Contractor: Oc G-IQ, A r" U L�V <br /> Mailing Address: Sbl S S70c-L70, p, V" <br /> Telephone Number: <br /> Contact Person on Site: 6#1-Ik pf� <br /> Site Phone Number: <br /> ❑ UTILITIES <br /> Source of Facility Water Supply: C i; p c- <br /> Backflow Protection: F, <br /> System to be used for Liquid Waste Disposal (Sewage): N <br /> Solid Waste Disposal to be provided: C iZt- kpoKjQ (,_E <br /> Grease Interceptor: <br /> ❑ FOOD,INFORMATION <br /> List food(s) to be served and/or provide menu: <br /> 6o34 mit_" -trsA I cr& i N%A 10 Icliz G r_;� wl <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 />