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Please provide all information requested; an incomplete application may delay approval <br />❑ FACILITY INFORMATION <br />Name of Facility: OSA SUec-P, q%+9KC5� <br />Street Address: I Or— MA-AGH Wwe <br />I R <br />City: �� -p c.>Grp <br />Zip Code: 15W-7 <br />FORMER NAME OF FACILITY <br />f' 1A <br />❑ BUSINESS OWNER INFORMATION <br />Business Owner Name: A10H1 K:IMAP- <br />0cv6A-J <br />Home Address: 2,411 0 IR STIP <br />CrOWTO/d E* 1 -LO 4j <br />Mailing Address: <br />Telephone Number: <br />❑ PROPERTY 0WI-ER INFORMATION <br />Property Owner Name: fAV' <br />Home Address: J1QW0tj <br />Mailing Address: <br />Telephone Number: .1, O 50 OI <br />❑ CONTRACTOR INFORMATION <br />Mik,_ <br />Name of General Contractor: MOMIT <br />Mailing Address: <br />(A— <br />Telephone Number: lto <br />Contact Person on Site: <br />Site Phone Number: }p <br />❑ UTILITIES <br />Source of Facility Water Supply: C#L WA0rj6]lZ— <br />Backflow, Protection: I#t j[_, <br />System to be used for Liquid Waste Disposal (Sewage): Sf0 k rN <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 />1140 00 <br />Nl- 1�0 F rG <br />❑ OPERATIONAL INFORMATION <br />Anticipated Business Hours: Open: <br />1\ PM Close: qPM <br />Anticipated Number of Employees: <br />EHD 16-01 4 PLAN CHECK GUIDE <br />6/28/2022 <br />