MY SONG PEKINGESE PARK.PDF

Maricopa County
Animal Care And Control
2500 South 27th Avenue
Phoenix, AZ 85009
(602) 506-7387 Tele.
(602) 506-2739 Fax
KENNEL PERMIT APPLICATION
CI New Renewal Permit # 13
Name: Ye, I.. AA4 Kennel Name:
Mailing Address: .4 04,--( Kennel Location: "j Z.2-) ()
city 'tfin,-e0-7<- I (b- , AZ ZIP County Supervisorial District
Home Phone: Kennel Phone: (CO g g/ 57'7'
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 for a scheduled
inspection and/or 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. Iy& I/VVe assume complete responsibility for the kennel at the premises for which I/we are making
appbcation 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. I/We 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. I/VVe certify that I/We have I dogs and that the kennel meets the definition in statute.
4. L it I/VVe certify that IANe have not been convicted of a violation of A.R.S. §§ 13-2910 (cruelty to animals)
or 1 91 0.01 (dog fighting), or any other state, county or municipal animal welfare law. (Violations of license
and leash laws DO NOT apply.)
5. 91 h•t. I/VVe certify that all dogs over the age of three (3) months that are kept, harbored or maintained on the
pren*es 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.

7. PO I/VVe understand that a dog remaining within the kennel is not required to be licensed individually under
AR ' 11-1008. I/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.
t/ - Y1
INVe understand that a person who fails to obtain a kennel permit under ARS 11-1009 is subject to a
penalty -of twenty-five dollars in addition to the annual fee.
1 / /
A(/1
6. ,/ I /We certify that IMIe are submitting a valid copy of the rabies vaccination certificate for each
dogiW'Aqi this application.
9. understand that a person who knowingly faiis to obtain a kennel permit within thirty days after written
notifiCation from the county enforcement agent is guilty of a class 2 misdemeanor.
/11/1/1
10. VP Is this kennel permit being obtained for the purposes of operating a business including butj3pt1imlted to
bree rs, groomers or boarding establishments? (Please check one) _DYES 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. § 41-1080(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 law:
J 1. An Arizona driver license issued after 1996 or an Arizona non-operating identification
license.
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 i-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 an wer to question 10. above is "NO" please answer question 11.
11. Vj. I/We certify that the kennel permit is being used solely for the purpose of licensing my own multiple
companion dogs in my household.
I/We certify that all of tlinjormation INVe have provided is true and accupte ynder penalty of law.
X _12 --/4 .--;,?.__ /./ ,-,-- ----i- // (,--, /
_Date: 7--'i I ..&'---- (9 , ,.., -(--7/
i
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 Animal Care and Control
2500 S. 27th Avenue
Phoenix, AZ 85009-6797
(602) 506-7387
http://pets.maricopa.gov
Receipt Number: R13-150758 Receipt Date: 0713012013
Person ID: P0999290
Phone: 602 8415740
MY SONG PEK PK KENNELS
3221 W ALICE AVE 7/30/2013 11:21:46AM
PHOENIX, AZ 85051
Item: Animal ID: Reference No: Price: Each: Amount:
KEN PERMIT A7777777 K14-000033 $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: Animal# Vacc Date: Vacc Expires:
Please retain this receipt with your pet's records
KJENSEN EBUSOFF

Page 14 of 14
RABIES VACCINATION CERTIFICATE IteldesTag Number
HASPI-IV Form $ I
PRINT - use ballpoint pen or type M.I. Telephone
IL Address
(o'D
No. Scree COLORS
Male
Female
Neutered
VETERINARIAN:
DATE VACCINATED: &10-D-cl
PRODUCER: tent
JJ Li 0A)
Month Day Year (First 3 letters)
VACCINATION EXPIRES: I yr. Uc. /Vaccine ji 0 • Veterinarian's alatere i-toPeita\
3 yr. Lk. /Vaccine 1)4m te,n hot
ju , 9 srui
Address: Irri
Month Day (-LP Photrity.„2/1-_
ccine Serial (Lot)
RABIES VACCINATION CERTIFICATE
NASPHV Form 050
Owner's Name & Address Print - use ball point pen or type
PRINT - Last First
0
No.
2-2-Tee'w Pei 62, Ante." 1>
Species: Sex: Age:
Dog t5e. Male CI 3 mo. to 12 mo.
Cat 13 Fema1e-3;g- 12 ma. or older.
Namel-e0„7...v
Producer
NIP AND SNIP MOBILE
SPAYMEUTEB_CLINIn

Page 13 of 14
North Central Animal Hospital, P.C.
RABIES VACCINATION CERTIFICATE
OWNER'S INFORMATION ANIMAL INFORMATION
Client ID: 4737 Patient ID: 4829
Client Name: Yolanda Martin Patient Name: Winter Wonder Land
3221 W Alice Ave Species: Canine
Phoenix, AZ 85051 Breed: Pekingese
Sex: Female
Color: Tr-Color
Phone: (602) 841-5740 Birthday: 11/9/2012
Weight 8.3 pounds
VACCINATION INFORMATION
Vaccine Producer: Merial Vaccine Type: Killed Virus
Vaccine Lot*: 18181B Vaccine Length: 1 year(s)
Date Vaccinated: 4/13/2013 Print Date: 4/13/2013
Vaccine Vial Expires: 12/11/2013
North Central Animal Hospital, PC
20 W Dunlap Ave
Phoenix, Arizona 85021
ff& 5- (602) 395-9773
Veterinarian's Signature: Felicitas Tantiyatyanon
Veterinarian's License Number 76

Page 12 of 14
North Central Animal Hospital, P.C.
RABIES VACCINATION CERTIFICATE
OWNER'S INFORMATION ANIMAL INFORMATION
Client ID: 4737 Patient ID: 4442
Client Name: Yolanda Martin Patient Name: Pinocchio
3221 W Alice Ave Species: Canine
Phoenix. AZ 85051 Breed: Pekingese
Sex: Male
Color:
Phone: (602) 841-5740 Birthday: 6/30/2011
Weight - 7.3 pounds
VACCINATION INFORMATION
Vaccine Producer: Menai Vaccine Type: Killed Virus
Vaccine Lot # 181758 Vaccine Length: 3 year(s)
Date Vaccinated: 12/30/2012 Print Date: 12/30/2012
Vaccine Vial Expires 9/30/2013
North Central Animal Hospital, PC
20 W Dunlap Ave
'7 Phoenix, Arizona 85021
• ---. (602) 395-9773
'Veterinarian's Signature Hillary Frank
Veterinarian's License Number 76

Page!! of 14
RABIES VACCINATION CERTIFICATE Rabies Tag Number
NASPHV Form Si
PRINT - use ballpoint pen or type
Owner's Name &Address Telephone
cJL-
tem_ ;-013-
COLORS:
SPECIES: 101
Dog
Cat El NAME: (r s
Other 0
Please specify eld (vi
VETERINARIAN:
DATE VACCINATED:
PRODUCER: F
'eterinailth's #:
ticens
Month Day ' Year First 3 letters)
VACCINATION EXPIRES: I yr. Lic. /Vaccine K. 0 Veterinarians al ture- lic)
3 yr. Uc. /Vaccine tr) nirnatt Vh347
t4 [Ajdal dressirm aye,.
Year N. 43 4,
Month Day
Vaccine Serial (Lot) No
RABIES VACCINATION CERTIFICATE
NASPHV Forrn 51 Rabies Tag Number
Owner's Name &Address PRINT - use ballpoint pen or type
Last . First M.1. Telephone
YVe nig t ( 1 I euel4 Se-
No. Street . City State Zip
pp\ \iv. Aii ciL ;AA IL (it vi : y , A-2_
SPECIE : SEX: AGE: IZE: PREDOMINANT BREED:
Dog Male 14 3 mo.- 12 mo. 0 Under 20 lbs.& jr,1.1 IL COLORS:
Cat 0 Female 0 12 mo. or olde00 20 - 50 lbs. 0 fit nin9-es—e ../. Lot An
Other 0 Neutered 0 Over 50 lbs. 0
Please specify NAME: \)5-A-- eA vvvki--i-citt
...
c)
DATE VACCINATED: VETERINARIAN:
I 1 G), _ j 0 PRODUCER) ":"-- 7_
. veterinars#: 1 --K)-- gat
Month Day ' Year /
First 3 letters Licens9N. -
0
VACCINATION EXPIRES: I yr. Lic. /Vaccine 0 i k
3 yr. Lit. /Vaccine XI Veterinarian's Sig ii. r
II 11 13 p/iz.7-2 A--a , ,',/-74 / 22V fp
Month Day 'Year 5 dif h9....t..7)A....... Address: 977j 0j,z./.3 -
4.
Vaccine Serial (Lot) No.
, 42_ Rc6S /

Page 10 of 14
North Central Animal Hospital, P.C.
RABIES VACCINATION CERTIFICATE
OWNER'S INFORMATION ANIMAL INFORMATION
Client ID: 4737 Patient ID: 3516
Client Name: Yolanda Martin
Kennel Permit 33 Patient Name: Herbie
3221 W Alice Ave Species: Canine
Phoenix, AZ 85051 Breed: Pekingese
Sex: Male
Color: Gray
Phone: (602) 841-5740 Birthday: 2/11/2012
Weight: 11.5 pounds
VACCINATION INFORMATION
Vaccine Producer. Medal Vaccine Type: Killed Virus
Vaccine Lot #: 18193C Vaccine Length: 3 year(s)
Date Vaccinated: 7/7/2013 Print Date: 7M2013
Vaccine Vial Expires: 12111/2013
North Central Animal Hospital, PC
20 W Dunlap Ave
Phoenix, Arizona 85021
, (602) 395-9773
7 1
'eferinaria,r*Signature: Hillary Frank
Veterinarian's License Number 76

Page 9 of 14
North Central Animal Hospital, P.C.
RABIES VACCINATION CERTIFICATE
OWNER'S INFORMATION ANIMAL INFORMATION
Client ID: 4737 Patient ID: 3515
Client Name: Yolanda Martin
Kennel Permit 33 Patient Name Lovenote
3221 W Alice Ave Species: Canine
Phoenix, AZ 85051 Breed: Pekingese Mix
Sex: Female
Color Fawn
Phone: (602) 841-5740 Birthday: 1/21/2012
Weight: 8.6 pounds
VACCINATION INFORMATION
Vaccine Producer: Merle! Vaccine Type: Killed Virus
Vaccine Lot #: 18193C Vaccine Length: 3 year(s)
Date Vaccinated: 7/7/2013 Print Date: 7/712013
Vaccine Vial Expires: 12/11/2013
North Central Animal Hospital, PC
20W Dunlap Ave
/ Phoenix, Arizona 85021
(602) 395-9773
/
Veterinarian' gnature: Hillary Frank
Veterinarian's License Number 76

Page 8 of 14
North Central Animal Hospital, P.C.
RABIES VACCINATION CERTIFICATE
OWNER'S INFORMATION ANIMAL INFORMATION
Client ID: 4737 Patient ID: 3780
Client Name: Yolanda Martin Patient Name: Baby Doll
3221 W Alice Ave Species Canine
Phoenix. AZ 85051 Breed: Pekingese
Kennel Permit 33 Sex: Female
Color Gold & White
Phone: (602) 841-5740 Birthday: 7/13/2011
Weight 13.9 pounds
VACCINATION INFORMATION
Vaccine Producer: Menai Vaccine Type: Killed Virus
Vaccine Lot* 18193C Vaccine Length: 3 year(s)
Date Vaccinated: 7/26/2013 Print Date: 7/26/2013
Vaccine Vial Expires: 12/11/2013
North Central Animal Hospital, PC
20 W Dunlap Ave
Phoenix, Arizona 85021
(602) 395-9773
z( )2
Ve rinariaVSignature: Hillary Frank
Veterinarian's License Number 76
RABIES VACCINATION CERTIFICATE
NASPHV Form 51 Rabies Tag Number
Owner's Name &Address PRINT. use ballpoint pen or type
MI. Telephone
'il‘c,nnd Li cense *Igqt
(.0091)(64-1-
ga9C'ehestAtiche PrIx {g5C51
SPECIE SEX: AGE: SIZE: PREDOMINANT BREED: COLORS:
Dog Male 3 mo.- 12 mo. Under 20 lbs.g Pe
Cat 0 Female 12 mo. or olderpC 20 - SO lbs. Ki ne5e
Other 0 Neutere Over SO lbs. 0 NAME: MA SOn
Please specify
\i -enir1951nr"
DATE VACCINATED: VETERINARIAN:
11 la voi PRODUCER:0
Month Day Year erinariaftc
First 3 letters) Lice
VACCINATION EXPIRES: I yr. Lic./VaccineNg.
3 yr. Lit. /Vaccine Veterinarians S i
11 11 13 ik
osm
Month Day Year c5'4"t2a51)14 Address: 177/ 44:5/_2_—/
Vaccine Serial (Lot) No.
v CAS

Page 7 of 14
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 Chene
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: 145 pounds
VACCINATION INFORMATION
Vaccine Producer: Menai Vaccine Type: Killed Virus
Vaccine Lot #: 18193C Vaccine Length: 3 year(s)
Date Vaccinated: 7/26/2013 Print Date: 7/26/2013
Vaccine Vial Expires. 12/11/2013
North Central Animal Hospital, PC
20 W Dunlap Ave
Phoenix, Arizona 85021
(602) 395-9773
Ve erinarian%(Signature Hillary Frank
Veterinarian's License Number 76

08/02/2013 09:15 6028709282 OFFICEMAX 418