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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 New g Renewal Permit # 033 Name: YO lat/C6 Kennel Name: 111A S rA Perk VAA ys e (lc Mailing Address: 3-)9 Kennel Location: ;-9r) LA.). Aff-e.„ City )(\ y_ , AZ ZIP ?Spri County Supervisorlaf District 3 Kennel Phone: o. - 391-5'd Please 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 "operating a kennel" must obtain a permit issued by the Board of Supervisors where the kennel is located except if each individual dog is licensed. A.R.S. § 11- 1009 and MC Ordinance No. 13, Sec. 4. define a "kennel" 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 andlor failure of inspection will warrant a Subsequent inspeCtion Return fee of $49 for each additional visit. Failure of inspection may require individual licensing of each dog under the provisions of ARS 11-1008. PLEASE ANSWER THE FOLLOWING QUESTIONS Initial Each 1. I/We assume complete responsibility for the kennel at the premises for which Itwe are making appl tion 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. 4/1,A INVe certify that the kennel has been approved by the local zoning authority (if applicable) at the premises for which I/we are making application for a permit. 3. IA iA INVe certify that INVe have 6 dogs and that the kennel meets the definition in statute. 1/We certify that INVe have not been convicted of a violation of A.R.S. §§ 13-2910 (cruelty to animals) 10.01 (dog fighting), or any other state, county or municipal animal welfare law. (Violations of license laws DO NOT apply.) 5. 'III ' I INVe certify that all dogs over th.Q . age of three (3) moplis that are kept, harbored or maintained on the prenses 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. I /We certify that INVe are submitting a valid copy of the rabies vaccination certificate for each this application. • 741 I/We understand that a dog remaining within the kennel is not required to be licensed individually under ARS v11-1008. 1/we also understand that a dog leaving the controlled kennel conditions shall be licensed under ARS 11-1008 except if the dog is only being transported to another kennel which has a permit issued under this section. 8. wig, INVe understand that a person who fails to obtain a kennel permit under ARS 11-1009 is subject to a pen* of twenty-five dollars in addition to the annual fee. • 14.t INVe understand that a person who knowingly fails to obtain a kennel permit within thirty days after writter notification from the county enforcement agent is guilty of a class 2 misdemeanor. 10 Vs this kennel permit being obtained for the purposes of operating a business including but not limited to br rs, \groomers or boarding establishments? (Please check one) YES \/NO If the answer is "YES", you will need to provide proof of lawful presence in the United States in order to obtain a kennel permit for the purposes of operating a business. The forms of identification accepted for this purpose are listed below. A.R.S. § 4171080(A) provides: After September 30, 2008, an agency or political subdivision of this state shall not issue a license to an indiVidual if the individual does not present any of the following documents to the agency or political subdivision indicating that the individual's presence in the United States is authorized under federal An Arizona driver license issued after 1996 or an Arizona non-operating identification license. • 2. A driver license issued by a state that verifies lawful presence in the United States. 3. A birth certificate or delayed birth certificate issued in any state, territory or possession of the United States. 4. A United State certificate of birth abroad. 5. A United States passpOrt. 6. A foreign passport with a United States Visa. 7. An 1-94 form with a photograph. 8. A United States citizenship and immigration services employment authorization document or refugee travel document. 9. A United States certificate of naturalization. 10. A United States certificate of citizenship. 11. A tribal certificate of Indian blood. 12. A tribal or bureau of Indian affairs affidavit of birth. Please submit a photocopy of both the front and back of your identification with your completed application. Please also be prepared to present your identification at the time of inspection by the field services officer. If the answer to question 10. above is "NO" please answer question 11. 11. ']/V1/We certify that the kennel permit is being used solely for the purpose of licensing my own multiple com4nion dogs in my household. I/We certify that all of the information I/We have provided is true and accurate under penalty of law. Applicant Signature Date: 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 BUS Approval Date Term of Permit Maricopa County Animal Care and Control 2500 S. 27th Avenue Phoenix, AZ 85009-6797 (602) 506-7387 http://pets.maricopa.00v Receipt Number: R14-138533 Receipt Date: 07/15/2014 Person ID: P0999290 Phone: 602 8415740 MY SONG PEK PK KENNELS 3221 W ALICE AVE 7/15/2014 11:30:39AM PHOENIX, AZ 85051 Item: Animal ID: Reference No: Price: Each: Amount: KEN PERMIT A7777777 K15-000033 $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 9/14/1999, SPAYED, UNKNOWN/MIX, TRICOLOR DOG License Information: Tag Number: License Expires: AnimaI# Vacc Date: Vacc Expires: Please retain this receipt with your pet's records reyesa EBUSOFF Page 9 of 9 North Central Animal Hospital, P.C. RABIES VACCINATION CERTIFICATE OWNER'S INFORMATION ANIMAL INFORMATION Client ID: 4737 Patient ID: 6821 Client Name: Yolanda Martin Patient Name: Zena 3221 W Alice Ave Species: Canine Phoenix, AZ 85051 Breed: Chihuahua Mix Sex: Female Color: Gray Phone: (602) 841-5740 Birthday: 3/20/2014 Weight: 6.2 pounds VACCINATION INFORMATION Vaccine Producer: Merial Vaccine Type: Killed Virus Vaccine Lot #: 18214A Vaccine Length: 1 year(s) Date Vaccinated: 7/6/2014 Print Date: 7/6/2014 Vaccine Vial Expires: 4/24/2020 North Central Animal Hospital, PC 20 W Dunlap Ave Phoenix, Arizona 85021 its, ALUM (602) 395-9773 Vetenn ature: Ivy Thom / bterinarian's License Number 76 Page 8 of 9 North Central Animal Hospital, P.C. RABIES VACCINATION CERTIFICATE OWNER'S INFORMATION ANIMAL INFORMATION Client ID: 4737 Patient ID: 6822 Client Name: Yolanda Martin Patient Name: Diana 3221 W Alice Ave Species: Canine Phoenix, AZ 85051 Breed: Pekingese Sex: Female Color: Tr-Color Phone: (602) 841-5740 Birthday: 3/20/2014 Weight: 3.7 pounds VACCINATION INFORMATION Vaccine Producer: Menial Vaccine Type: Killed Virus Vaccine Lot #: 18214A Vaccine Length: 1 year(s) Date Vaccinated: 7/6/2014 Print Date: 7/6/2014 Vaccine Vial Expires: 4/24/2020 North Central Animal Hospital, PC 20 W Dunlap Ave Phoenix, Arizona 85021 (602) 395-9773 Page 7 of 9 North Central Animal Hospital, P.C. RABIES VACCINATION CERTIFICATE OWNER'S INFORMATION ANIMAL INFORMATION Client ID: 4737 Patient ID: 6466 Client Name: Yolanda Martin Patient Name: Autumn 3221 W Alice Ave Species: Canine Phoenix, AZ 85051 Breed: Pekingese Sex: Female Color: Red Phone: (602) 841-5740 Birthday: 10/14/2013 Weight: 11.4 pounds VACCINATION INFORMATION Vaccine Producer; Merial Vaccine Type: Killed Virus Vaccine Lot #: 18203A Vaccine Length: 1 year(s) Date Vaccinated: 4/22/2014 Print Date: 4/22/2014 Vaccine Vial Expires: 11/25/2015 North Central Animal Hospital, PC 20 W Dunlap Ave Phoenix, Arizona 85021 (602) 395-9773 Page 6 of 9 North Central Animal lospital, P.C. RABIES VACCINATION ERTIFICATE OWNER'S INFORMATION ANIMAL INFORMATION Client ID: 4737 Patient ID: 5598 , Client Name: Yolanda Martin Patient Name: Billy Jean 3221 W Alice Ave Species: , Canine Phoenix, AZ. 85051 Breed: Pekingese Kennel Permit #33 Sex: Spayed Female Color: Black Phone: (602) 841-5740 Birthday: 6/1/2013 Weight: 6.5 pounds VACCINATION INF: - :AVIATION Vaccine Producer: Merial Vaccine ,pa: Killed Virus Vaccine Lot #: 18194C Vaccine ngthi year(s) Date Vaccinated: 10/20/2013 Print Da .:, 10/20/2013 Vaccine Vial Expires: 12/11/2013 North Central Animal Hospital, PC 20 W Dunlap Ave Phoenix, Arizona 85021 (602) 395-9773 Veterinarra0's /,61g0a re: Ivy Thomas Veterinarian's License Number 76 Page 5 of 9 North Central Animal Hospital, P.C. RABIES VACCINATION CERTIFICATE OWNER'S INFORMATION ANIMAL INFORMATION Client ID: 4737 Patient ID: 3779 Client Name: Yolanda Martin Patient Name: Chimy Chimy Cherie 3221 W Alice Ave Species: Canine Phoenix, AZ 85051 Kennel Permit 33 Breed: Pekingese Sex: Female Color: White Phone: (602) 841-5740 Birthday: 6/11/2011 Weight: 14.5 pounds VACCINATION INFORMATION Vaccine Producer: Merial Vaccine Type: Killed Virus Vaccine Lot #: 18193C Vaccine Length: 3 year(s) Date Vaccinated: 7/26/2013 Print Date: 7/2612013 Vaccine Vial Expires: 12/11/2013 North Central Animal Hospital, PC 20W Dunlap Ave Phoenix, Arizona 85021 (602) 395-9773 Veterinarian's License Number 76 North Central Animal Hospital, P.C. RABIES VACCINATION CERTIFICATE OWNER'S INFORMATION ANIMAL INFORMATION Client ID: 4737 Client Name: Yolanda Martin Patient ID: 5592 3221 VV Alice Ave Patient Name: Eve Phoenix, AZ 85051 Species: Canine Breed: Pekingese Sex: Female Phone: (602) 841-5740 Color: Black/Gold Birthday: 6/29/2009 Weight: 12.5 pounds VACCINATION INFORMATION Vaccine Producer: Medal Vaccine Type: Killed Virus Vaccine Lot #: 18203A Vaccine Length: 3 year(S) Date Vaccinajedt„ 12/1/2413 Print Date: 12/1/2013 Vaccine Vial- Expires: 1/25/2015 North Central Animal Hospital, PC 20 W Dunlap Ave .)411 Phoenix, Arizona 85021 (602) 395-9773 6 Xiff .i Iv7Thoma arian's License Number 76