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Please provide all information requested; an incomplete application may delay approval <br /> ❑ FACILITY INFORMATION <br /> Name of Facility: p l 'V ri <br /> Street Address: 502 {moo AV Z . <br /> City: a Zip Code: S 2 U <br /> ❑ FORMER NAME OF FACILITY <br /> t�,twvv slALC,N <br /> CI RUSINES9 OWNER INFORMATION <br /> Business Owner Name: Mo res \L f\c,l ck <br /> Home Address: + 13y L . ujok�, A a C CIS-.4-1:1-0 <br /> Mailing Address: P C, BoK C <br /> Telephone Number: zc; c - C; ` <br /> ❑ PROPERTY OWNER INFORMATION <br /> Property Owner Name: �Vl 1 � �s:OiC� . . .i70 <br /> Home Address: ' (p0 2� <br /> Mailing Address: <br /> Telephone Number: <br /> ❑ CONTRACTOR INFORMATION <br /> Name of General Contractor: i C> <br /> Mailing Address: '^p 7 (tQ�L_ LC)Ot C S` <br /> Telephone Number: _ p_ 2 <br /> Contact Person on Site: l4 <br /> Site Phone Number: <br /> O UTILITIES uL s <br /> Source of Facility Water Supply —, 00 i <br /> Backflow Protection: qP <br /> System to be used for Liquid Wase Disposal ( ewage): Ca + n i_ Lpp <br /> Solid Waste Disposal to be provided: N <br /> Grease Interceptor: <br /> ❑ FOOD INFORMATION <br /> List foods to be served and/or provide menu: <br /> +IQ,t� alk Fe slnct.V�Gs <br /> AAkxw,oie, — q$' <br /> ❑ OPERATIONAL INFORMATION <br /> Anticipated Business Hours: Open: £3.30o.m Close: <br /> Anticipated Number of Employees: <br /> EHD 76-07 4 <br /> 7/5/17 PLAN CHECK GUIDE <br />