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Please provide all information requested; an incomplete application may delay approval <br />(FACILITY IN MATION , <br />Name of Facility: I p p 416o - " p <br />Street Address: d p <br />City: 5 50 <br />0 o Zip Code: 2 <br />R NAME OF FACILITY <br />t4 <br />)USINESS OWNER INFORMATI <br />Business Owner Name: ("I (fiCp F -w1 -DS LLCI <br />Home Address: p I.I, g - <br />Mailing Address: a <br />Telephone Number: ZL2g p <br />❑ PROPERTY OW IMMAMM <br />Property Owner Name: AS <br />Home Address: <br />Mailing Address: <br />Telephone Number: <br />FORMATIO . <br />Name of General Contractor: <br />Mailing Address: <br />Telephone Number: <br />Contact Person on Site: <br />Site Phone Number: <br />dAftbES <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 />❑6 INFORM/X <br />List food(s) to be served and/or provide menu: <br />Anticipated Business Hours: Q Open: Close: <br />Anticipated Number of Employees: <br />EHD 16-01 4 PLAN CHECK GUIDE <br />7/5/17 <br />