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Please provide all information requested; an incomplete application may delay approval <br />FACILITY INFORMATION <br />Name of Facility: l -or _ , <br />Street Address: U,00 C.C1*Cr G+1 <br />City: IS71V L*ra-\ S'LOZ <br />Zip Code: <br />10 FORMU NAME OF FACILITY <br />pg BUSINESS OWNER INFORM ION <br />Business Owner Name: <br />DoN <br />Home Address: <br />Mailing Address: 1101 LyjCA- <br />95MI <br />Telephone Number: 2-09) -7-7-7`-ZS- <br />fiO PROPERTY OWNER INFORMATION <br />Property Owner Name: M. <br />Home Address: yI tyl}, <br />Mailing Address: Lx <br />Telephone Number: ZC)q -I- <br />CONTRACTOR INFORMATION <br />Name of General Contractor: Jig,, C"C,k*LVZ, <br />= tx1Y1Qf - U1(� <br />Mailing Address: 101 v+ tt ' <br />4 <br />Telephone Number: 717 - <br />Contact Person on Site: f1l rijayl Ci ut L l <br />0 3 o zS,$' <br />Site Phone Number: �R - <br />❑ UTILITIES <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 />❑ FOOD INFORMATION <br />List food(s) to be served and/or provide menu: <br />❑ OPERATIONAL INFORMATION <br />Anticipated Business Hours: Open: <br />Close: <br />Anticipated Number of Employees: <br />EHD 1"1 4 PLAN CHECK GUIDE <br />8101/16 <br />O • <br />