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Please provide all information requested; an incomplete application may delay approval <br /> ❑ FACILITY INFORMATION <br /> Name of Facility: , -��j W 71 <br /> Street Address: ()5 v4, I noin Af. <br /> City: P,1, on Zip Code: J-3 <br /> ❑ FORMER NAME OF FACILITY <br /> ❑ BUSINESS OWNER INFORMATION <br /> Business Owner Name: V411661/1 <br /> Home Address: o ,v)D JD j2, &),I f1 09-3 <br /> Mailing Address: <br /> Telephone Number: 2,pe' — 015 - G-?p <br /> ❑ PROPERTY OWNER INFORMATION <br /> Property Owner Name: <br /> Home Address: <br /> Mailing Address: i o t2 j pvi t44 61S-3(,PCP Sy6tc <br /> Telephone Number: -2 t)491- c5 6?9 (0q <br /> ❑ CONTRACTOR INFORMATION <br /> Name of General Contractor: <br /> Mailing Address- <br /> Telephone Number: <br /> Contact Person on Site: <br /> Site Phone Number: <br /> ❑ UTILITIES <br /> Source of Facility Water Supply: { <br /> Backflow Protection: <br /> System to be used for Liquid Waste Disposal (Sewage): /ha S1 v7 <br /> Solid Waste Disposal to be provided: 0-( U <br /> Grease Interceptor: N1 1+ <br /> ❑ FOOD INFORMATION <br /> List food(s) to be served and/or provide menu: <br /> atf �v s <br /> ❑ OPERATIONAL INFORMATION <br /> Anticipated Business Hours: Open: JM-Jett fU/qni Close: ivl-1--' al J6-f <br /> Anticipated Number of Employees: <br /> EHD 16-01 4 PLAN CHECK GUIDE <br /> 715117 <br />