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Maricopa County Animal Care And Control 2500 South 27th Avenue Phoenix, AZ 85009 (602) 506-7387 Tele. (602) 506-2739 Fax KENNEL PERMIT APPLICATION D New K.Renewal Permit # 090 Name: S LA se. 10 X Kennel Name: A) X VO Vine Mailing Address:c97)(7 F.. Louis Q Dr, Kennel Location:05r)c- T,Lcx,6s-e P City P h De ( gq.)34 County Supervisorial District 3 Home Phone: Kennel Phone: Pic.lase complete and sign this application and return it to the above address with payment in the amount of three hundred twenty eight dollars ($328.00) within ten (10) days of receipt. Pursuant to Arizona statute and county ordinance, a person must obtain a kennel permit issued by the Board of Supervisors if the person operates a kennel in which there are five or more dogs which are not individually licensed. A.R.S. §11-1009(A). A kennel is defined as "an enclosed, controlled area, inaccessible to other animals, in which a person keeps, harbors or maintains five or more dogs under controlled conditions." A.R.S. § 11-1001(8). An appointment will be scheduled for inspection of the kennel premises by an Animal Control Officer upon receipt of this kennel permit application and fee. This kennel application properly executed and a copy of the inspection report will then be forwarded to, and must be approved by, the Maricopa County Board of Supervisors. The kennel permit form will be sent to you after approval and will be valid for one year from the date of the Board's approval. NOTE: Failure to show fora scheduled inspection and/or failure of inspection will warrant a Subsequent Inspection Return fee of $49 for each additional visit. Failure of inspection may result in denial of the kennel permit and require individual licensing of each dog under the provisions of A.R.S. §11-1008. PLEASE ANSWER THE FOLLOWING QUESTIONS AND INITIAL EACH RESPONSE 1. 7 1/We assume complete responsibility for the kennel at the premises for which I/we are making application for a permit and understand that "kennel" means an enclosed, controlled area, inaccessible to other animals, in which a person keeps, harbors or maintains five or more dogs under controlled conditions (ARS 11- 1001). 2. % INVe certify that INVe have 3 dogs and that the kennel meets the definition in statute. 3. V- I/We certify that I/We have not been convicted of a violation of A.R.S. §§ 13-2910 (cruelty to animals) or 13-2910.01 (dog fighting), or similar violations of any other state, county or municipal animal welfare law. (Violations of license and leash laws DO NOT apply). 4. 1r I/We certify that all dogs over the age of three (3) months that are kept, harbored or maintained on the premises of the above named kennel have been properly vaccinated against rabies by a veterinarian licensed to practice in the state of Arizona and that a current vaccination certificate signed by a licensed veterinarian is maintained on the premises for each dog. 5. \- I /We certify that I/We are submitting a valid copy of the rabies vaccination certificate for each dog with this application. 6. ri INVe understand that a dog remaining within the kennel is not required to be licensed individually under A.R.S. § 11-1008. 1/we also understand that a dog leaving the controlled kennel conditions shall be licensed under A.R.S. § 11-1008 except if the dog is only being transported to another kennel which has a permit issued under this section. 7. V I/VVe understand that a person who fails to obtain a kennel permit under A.R.S.§11-1009 is subject to a penalty of twenty-five dollars in addition to the annual fee. 8. .v INVe understand that a person who knowingly fails to obtain a kennel permit within thirty days after written notification from the county enforcement agent is guilty of a class 2 misdemeanor.. 9. /The undersigned understand that that the kennel permit does not authorize the operation of any type of business and is solely used for the purpose of licensing multiple dogs. I/We certify that all of the information I/We have provided is true and accurate under penalty of law. Applicant Signature Date: /1- 111 Applicant Signature Date: For Official Use Only: Copies of Valid Rabies Vaccination Certificates for each dog attached Copy of Person's Valid Identification Attached Type of Identification submitted BOS Approval Date Term of Permit Maricopa County 1'4- 36774 Animal Care & Control 2500 South 27th Avenue Phoenix, AZ 85009 Phone: (602) 5064387 pets.marieopa.gov KENNEL PERMIT PREMISE INSPECTION APPLICANT t STREET ADDRESS @SOS- E (Dui c CITY, STATE, ZIP Qf A z- Rro 33 PHONE ALTERNATE PHONE COUNTY DISTRICT 3 KENNEL LICENSE # 03aNUIVIBER OF DOGS 1. Are all dogs over the age of three months properly vaccinated for rabies and in possession of a valid rabies vaccination certificate? Yes No NOTE: Copies of each rabies vaccination certificate must be attached to the Kennel Permit Premise Inspection form. 2. Is the kennel an enclosed, controlled area, inaccessible to other animals, in which a person keeps, harbors or maintains five or more dogs under controlled conditions? Yes No CORRECTIVE ACTION NEEDED FOR COMPLIANCE AND DAYS GIVEN BEFORE REINSPECTION. (Note: There will be $49 re-inspect fee payable to the Inspector by check upon each return visit.) Deputy Enforcement Agent Date JS Maricopa County Animal Care and Control 2500 S. 27th Avenue Phoenix, AZ 85009-6797 (602) 506-7387 http://pets.maricopaqov Receipt Number: R14-226714 Receipt Date: 11/14/2014 Person ID: P1152886 Phone: 602 4826975 NIX KENNELS 2505 E LOUISE DR 11/14/2014 11:35:03AP PHOENIX, AZ 85032 Item: Animal ID: Reference No: Price: Each: Amount: KEN PERMIT A7777777 K15-000032 $328.00 1 $328.00 Total Fees Due: $328.00 Payments: Cash: $0.00 Check: $328.00 Credit Card: $0.00 Total Payments Received: $328.00 Thank You! Would you like to share your experience with our service to you? Change: $0.00 Please visit our website at http://pets.maricopa.gov and click on Balance Due: $0.00 "Contact Us" to email your comments for our review. Animal Information: A7777777 KENNEL PERM - BORN 9/1411999, SPAYED, UNKNOWN/MIX, TRICOLOR DOG License Information: Tag Number: License Expires: Animal# Vacc Date: Vacc Expires: Please retain this receipt with your pet's records luffmanm EBUSOFF OMER'S copy RABIES VACCINATION CERTIFICATE NASPHV Form #51 Rabies Tag Number Owner's Name and Address Print - use ball point pen or type PRINT - Last _ 1 , First M.I. Telephone ' cow- 12)-Ilit No. , _ _ Street_ N ri( , • City , f statere. skos2 • - o x , 65 '.: 1 otAiGe. Dr PI-ten 1 5( Species: Sex: Age: Size: Predominant Breed: Colors: Dog Of Male le 3 mo to 12 mo 0 Under 20 lbs.174 v--- • I L 1.' k0 rolocte Cat CI Female 0 12 mo or older jg 20 -50 lbs. 0 tiaLWX,tACI Other: CI Neutered 0 Actual Age I by Over 50 lbs. 0 (Specify) Actual ) t lbs. Name: Frext DATE VACCINATED: Producer: f I Veterinarian's: # . icense 1 aNr1 .) AZ (First 3 letters) 0 i ) I c) Day Year (Signal 0- 0 1 yr. Lic./Vacc. Address: 031 3 yr. Lic./Vacc. VACCINATION EXPIRED: Other ' )5 E. 0-1 _6 51 .7406?-58e) -km pe f nz, 2 -,71 Month Day Year Vacc. Serial (lot) no. °INNER'S copy RABIES VACCINATION CERTIFICATE NASPHV Form #51 Rabies Tag Number Owner's Name and Address Print - use ball point pen or type PRINT - Last First M.I. Telephone Le- Lth3-42)--i.MI5 No. treet City ,--,, ., State Zip _ LczA-iae,. V mei') I X Pt7 tiO9 Species: Sex: Age: Size: Predominant Breed: Colors: Dog X Male 0 3 mo to 12 mo 0 Under 20 lbs. 0 i-. ri I-S c Cat 0 Female X 12 mo or older M 20- 50 lbs. 0 1`441-4 Other: 0 Neutered 0 Actual Age—l\/ Over 50 lbs. 0 tePecify) Actual 9 lbs. Name: c-1-0 rie l . DATE VACCINATED: Producer: p F - i i, Veerinarlant4 t 4..r.! . NI.) 412- Or-I 11 101 (First 3 letters) a, Month Day Year 0 1 yr. Lic./Vacc. (Signature) Address: ye3 yr. Lic./Vacc. VACCINATION EXPIRED: Other 3 07 ID Month Day Year Vacc. Serial (lot) no. RABIES VACCINATION CERTIFICATE Owner's Naorie &Address NASAF1V Form 5/ Rabies Tag Number Last PRINT - use ballpoint pen or type SA6" Mi. Tetlyito2ne Stret LOA \ S ,Dcel Ve) LNL zr oaL SPECIES: Dog AGE: SIZE: PREDOMINANT BREED: COLORS: Iv Cat 3 mo.- 12 mo. -0 Under 20 /1>s› aC)1(04Llit Other 0 12 mo.odcie.Q 20 - 50 lbs. 0 Please specify Over 50 lbs. 0 NAME: DATE VACCINATED: !...—fr VETERINARIAN: 14 PRODUCER: Month Day Year Ve terinaria First 3 letters Liceve--No. VACCINATION EXPIRES: 1 yr. Lic. /Vaccine 3 yr. /Vaccine veterinataNstPailgC-C-ED MENDS Month Day Year Address: E, Thuo(.1,...,.6ird, #59 Vaccine Serial (Lot) No. Phoenix,A 65032 NASPHV Form #51 Rabies Tag Number Owner's Name and Address Print - use ball point pen or type PRINT - Last First r ro,l Telephone No. • ) X NAR_ (f2,01:, - IA 75 a City y p Ina • Statefta re Li4x1)e4 0-e Species: Sex: Age: Size: Predominant Breed: Colors: Dog 7] Male 0 3 ma to 12 ma 0 Under 20 lbs.0 amicu aim_ ' 9- J k. Cat 0 Female % 12 moor o r IT 20 - 50 lbs. 0 Other: CI Neutered 0 Actual Age r Over 50As. 0 _1a41__c54 Specify) Actual -.) lbs. Name: Ltah . ATE VACCINATED: Producer: p Veterinatian's: # l'1161 CV r (License NO C' I LP (First 3 letters) A / 0-q37,110e Month Day Year 1 yr. Lic./Vacc. Slrjnature) VACCINATION EXPIRED: IV 3 yr. LiciVacc. Addresst E . 1.6* 61-, Other 3015 c4 P.1. IL" Cint-i 53-1 ) Month Day Year Vacc. Serial (lot) no. fe l e() Ai 21C->A1 OWNEITS COPY RABIES VACCINATION CERTIFICATE Rabies Tag Number NASPHV Form #51 Owner's Name and Address Print - use ball point pen or type M.I. Telephone PRINT - Last Street Age: Size: Predominant Breed: Colors: Species: Sex: Dog Male tiiJ 3 moto12 mop Under 20 lbs. ji41 Cat 0 Female 12 rno or older 20 - 50 lbs. 0 Other: Neutered 0 Actual Age Over 50 lbs. 0 Name: (Spectly) Actuali_Llbs, Veterinarian's: # 11:3141, 61 1 OZ- . DATE VACCINATED: Producer: P (First 3 letters) a4*-ek 61 ) 11, (Stgnettvs) Month Day Year El 1 yr.Lic./Vaoc. Address: 3 yr. LIc./Vaca. E b4- VACCINATION EXPIRED: Other p,e, 7.4 8 snti 1 -month Day Year Vacc. Serial (lot) no. OWNER'S COPY RABIES VACCINATION CERTIFICATE NASPHV Form #51 Rabies Tag Number Owner's Name and Address Print - use ball point pen or type PRINT - Last First Mi. Telephone (0114-11A3 -.0 % No. Street City es.. 5 ate Z eg 505 E Lowe. uje. f)-7, Species: Sex: Age: Size: Predominant Breed: Colors: Dog )3) Male lit" 3 mo to 12 mo 0 Under 20 lbs. Ig Cat 0 Female 0 -12 mo or older X 20 - 50 lbs. 0 teld Other: 0 Neutered 0 Actual Age Over 50 lbs. 0 (Specify) Actual )0 lbs Name: IZNA/461-1 ' _ DATE VACCINATED: Producer: t) Veterinarian's: # (l_rc enee ) ) r a.) PIZ- 71- q )L9 (3 (Fret 3 letters) ./ ' Pr45: Month Day Year 0 1 yr. Llo./Vacc. Posture) Address: 543 yr. LIc./Vacc. VACCINATION EXPIRED: . Other CA '6 0211 c(57 ii_e_ Piz-735AI Month 'Day Year Vac°. Serial (lot) no. OWNER'S COPY RABIES VACCINATION CERTIFICATE , NASPHV Form #61 Rabies Tag Number Owner's Name and Address Print - use ball point pen or type PRINT - Last , First r- M.1, Telephone ) ) C)t.1-11) tA14-LW -07; No. ' City State c.5 0Rtre 15 et--2 LOOdcar Dr PlIcv.fla6 Species: Sex: Age: Size: Predominant Breed: Colors: Dog 50 Male 0 3 mo to 12 mo 0 Under 20 lbs. N . Vtcl , Cat 0 Female i:ir 12 mo or older NO 20 -50 lbs. 0 Other: 0 Neutered 0 Actual Age r. Over 50 lbs. 0 P. (Specify) ActualltLibs, Name: exAbbieS DATE VACCINATED: Producer: p f- ,J Veterinarian's: # 11 Wit KZ- (License No. _n_ RP ) (First 3 letters) Month Day Year 0 1 yr. Llo./Vacc. (Signature) 9. 3 yr. Lic./Vac c, Addre ss: VACCINATION EXPIRED: 64,5 E /5-0- )A-- Other 01 6 _Ma ;$ 6Li 57 ) --wyfe, A-7„5.8Aft Month Day Year yam Serial (lot) no. . ()MIMS CaPY RABIES VACCINATION GERTIFIVA E NASPHV Form #51 Rabies Tag Number Owner's Name and Address . Print - use ball point pen or type PRINT - La , First e..-, M.I. Telephone st"\ 6 No.d50c)Stret , Lelva6x, Dr. City photx StateliZ saG %MD Species: Sex: Age: Size: Predominant Breed: Colors: Dog $ Male 0 3 mo to 12 mo 0 ,. Under 20 lbs, f54 wol_ , i j /11,100 k4e Cat 0. Female xi 12 moor cider Cil 26 - 50 lbs. EJ Pao Irianil ' . Other: 0 Neutered El Actual Age ti r Over 5010s. El (Specify) Actual 15 lbs. Name: Cool) DATE VACCINATED: Veterinarian's: # 1 $°1 4-7, Producer: F (License NO 9 -1L9. 13 (First 3 letters) A l'e-rniT: al-w-el/ Month Day Year 0 1 yr, LlolVacc. (SIgeature) io 3 yr. Llo./Vaco. Address; I CS- 41 n 54 VACCINATION EXPIRED: Other. • '71 i c5 1 6. Li 5.-7_i T erlye AZIT-191,/ Month Day Year . Vacc. Serial (lot) no. OWNVI'S COPY RABIES VACCINATION CERTIFICATE , NASPHV Form #51 Rabies Tag Number Owner's Name and Address Print - use ball point pen or type PRINT - Last I ' First,- ML Telephone kl i'?( le tra-t-leg - 62q75 No. Stree . City en Statev g) ,03):::9 0750S F L-nu ,147,-- Dr rlevx.xli x Species: Sex: Age: Size: Predominant Breed; Colors: Dog g Male P ii. 3 mo to 12 mo 0 Under 20 lbs. V panezaaiada_ p,Artc. ji Cat 0 Female 0 12 mo or older ad 20 -50 lbs. MI 1 Other: 0 Neutered 0 Actual Age Over 50 lbs, 0 ispecim Actual -7 lbs. Name: .. , rin e tite, DATE VACCINATED: Producer; p F. - Veterinarian's: # [1 -34:71, 62" (License No.} ci 1 tii r5 (First 8 letters} v Month Day Year 0 1 yr. tic,/ Vacc. (Signature) fE0 3 yr. LIc/Vaco, Address: VACCINATION EXPIRED: Other ac5 E 1(5-11—S4 q i b to 6 a?)Li 5-7 1 ---ro-re-ct r-12- "Z5 'a-i i Month Day Year Vacc. Serial (lot) no. . OWNER'S COPY RABIES VACCINATION CERTIFICATE , NASPHV Form #61 Rables Tag Number Owner's Name and Address Print - use ball point pen or type PRINT - Last First /...1 M.I. Telephone ..---)(Ae Iv -/-13,- VIZ No. .D05 Street , E._. . - , i_ritA,;, ,c, r City k P \ Tels‘ i \A. State } r,_-7 jt.. Zip__03e . . -6,- h Spades: g Sex: Age: Size: Predominant Breed: Colors: Dog Male 0 3 mo to 12 mo 0 Under 20 lbs. Cat Female 1 2 mo or older Vi 20 . 50 lbs. • i' "6-1' 61f‘tAnci 12.eci Other 0 Neutered g Actual Age Over 50 lbs. 0 ci (Specify) Actual..a_lbs. Name: ReCi DATE VACCINATED: Producer p p ..x , Veterinarian's: # Ilr Az (LIcense ) 6-7 I I la Prat 3 tatters) A 01\d-i Month Day Year 0 1 yr. Lic./Vacc. (Signature} nur kr3 yr. Lic./Vacc. Address: VACCINATION EXPIRED: 3t),b E , 16-1INSt: Other 61 1 IG 5 —lip .5 -6 6 Texyri er-2 .3(.a. Month Day Year Vacc. Serial (lot) no. N OWNER'S COPY liAbItO VAI...1.,11Piiii RAM tacri 1 or Iv/A i L NASPHV Form #51 Rabies Tag Number Owner's Name and Address Print - use ball point pen or type PRINT- Last First 0 Mi. Telephone U 1 V eDULA9 ( 1 a 4113 &116 No. a 506Stree_ City ',NI State A 2 zip CI r)(,(;i4et Or * II IV-cn Species: Sex: , Age; Size: Predominant Breed: Colors: Dog lit Male 0 3 ma to 12 ma El Under 20 lbs. KI r, „ eiack. Cat 0 Female X 12 mo or older 64 20 - 50 lbs. El LAVISVILtrici Other: 0 Neutered El Actual Age ( Over 50 lbs. El "1"Oun (8P8c[fy) Actual 1 lbs. Name: /401171b I DATE VACCINATED: VACCINATED: Producer: F F-,..._, r Veterinarian's: # 1 i '39 PIZ (1..(cense No.) 9 ,I,U,_ (First 3 letters) a, 67-0Z dj4l'e--"(7 Month Day Year El 1 yr. Lief Vacc. (Signature) . D5 E t64,frib+ Ni 3 yr. LiciVacc. Address: VACCINATION EXPIRED: Other Ter6p4, 141-Z, 9 6 p SNL(611 Month Day ear Vaoc. Serial (lot) no. OWNER'S COPY RABIES VACCINATION CERTIFICATE NASPHV Form #51 Rabies Tag Number Owner's Name and Address Print - use ball point pen or type PRINT - Last First , M.I. Telephone . fe 1 Y, bike_ to0D- V-166 Streq, City Statepri No c2' --- , 1-.0LAISe. f--)„. Pl-cen Species: Sex: f‘ i Age: Size; Predominant Breed: Colors; Dog IX Male Itt4 3 ma to 12 mo El Under 20 lbs,U , • Cat 0 Female 0 12 ma or older X 20 - 50 lbs. 111 Other: 0 Neutered 0 Actual Age ti y Over 50 liois. El , (Specify) Actualli_lbs Name: Le----P-44 0( DATE VACCINATED: Producer: p 'T. Veterinarian's: # (LIcenso ) I o.) (l Ai 0 (First 3 letters) all, 707\47:-/ Month Day Year 01 yr. Lie.! (Signature) V 3 yr. Lic./Vacc . Address : VACCINATION EXPIRED: Other ;6 E, 16-41-Si-. _Ca jOli )9, AZ- 82;1? I Month 'Day Year Vacc. Serial (lot) no. , "Tt"eYft-i OWNER'S COPY iwner's Name and Address NASPHV Form #51 Rabies Tag Number Print - use bail point pen or type 'FLINT - Last First Sim._ M.I. Telephone lo. k-)i Street. t,34 54 Lotti pA,... City pho.e n i x (60a`.. lir - 11115 State Zip , pecies: Sex: Age: Size: 19-2_ TEIO;Pe) log 14 Male 0 3 mo to 12 mo 0 Under 20 lbs. SI Predominant tbrst4.14 Breed: A t 1A. Colors: ;at 0 Female isi 12 mo or older NI 20 -50 lbs. 0 )ther: Ipeolfy) 0 Neutered 0 Actual Age_52..ye Over 50 lbs. 0 Actual. 1 lbs Name: I irtify &.I. i ,.., }ATE VACCINATED: Producer: e Veterinarian's: 4 (License No.) Cl 162 1‘ (First 3 letters) 1°01 Day Year r l')ix .),,' ‘4.410'e# 0 1 yr. LiciVacc, (Signature) 13 yr. LiciVacc. Address: ACCINATION EXPIRED: Other IVI- Si- T-e,ry-tp,L vl-Z Ze4:5n olonth Day Year -Vaco. Serial (lot) no. (