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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
O New Ef Renewal K2@- COCO24
Name: MWAvey (0/1 Kennel Name:_C/4n ar) Awe? §
Mailing Address: 20) jw) 7/Z24)) Svar cv Kennel Address: 726/ (2 Wize en Sepp 2K,
City: Cea _ State: AZ Zip:_ 450-53 City: Yagoy Zip:_ FX S253
County Supervisorial District: 26 | .
Phone: 423- Q/6S79 Kennel Phone: _ 623-V/o-g5° 77
Please complete and sign this application and return it to the above address with payment in the amount of three
hundred fifty dollars ($350.00) within ten (10) days of receipt.
NOTE: Failure to renew the kennel permit by the expiration date of the previous year kennel permit will result in
penalty fees for each dog being assessed at $6 per month for unaltered dog and $3 per month for altered dog in
addition to the permit fee. It is suggested the renewal application be submitted 4 — 6 weeks in advance of the
expiration date to allow timely processing.
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 for a scheduled inspection and/or failure of inspection will warrant a Subsequent
Inspection Return fee of $49 for each additional visit at time of inspection. 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. WC _ 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. 7\(_ We certify that I/We have // dogs and that the kennel meets the definition in statute.
3. fl C_\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. Nc 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. NC We certify that [We are submitting a valid copy of the rabies vaccination certificate for each
dog with this application.
6. NC iwe understand that a dog remaining within the kennel is not required to be licensed individually under
A.R.S. § 11-1008. I/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. WCeime 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. NC we 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. Tk tte 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.
We certify that all of the information I/We have provided is true and accurate under penalty of law.
Applicant Signature Yow: rtoo—— Date A / 28 /2 C2BO
-
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.
October 2015
Maricopa County Animal Care and Control
Receipt Number: R20-100223
CHAPMAN KENNELS
4201 W TIERRA BUENA LN
PHOENIX, AZ 85053
2500 S. 27th Avenue
Phoenix, AZ 85009-6797
(602) 506-7387
http://pets.maricopa.gov
Receipt Date: 03/11/2020
Person ID: P1246031
Phone: 602 8964019
3/11/2020 3:43:47PM
Item: Animal ID: Reference No: Price: Each: Amount:
KEN PERMIT A7777777 K20-000024 $350.00 1 $350.00
Total Fees Due: $350.00
Payments: Cash:
Check: $350.00
Credit Card:
Total Payments Received: $350.00
Would you like to share your experience with our service to you? Thank You!
Please visit our website at http://pets.maricopa.gov and click on "I Change: $0.00
Want To and Contact MCACC" to email your comments for our o : .
review. Balance Due: $0.00
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
johnsonk WBUSOFF
Maricopa County
Animal Care & Control
2500 South 27" Avenue
Phoenix, AZ 85009
Phone: (602) 506-7387
pets.maricopa.gov
KENNEL PERMIT K21-000024
PREMISE INSPECTION
Number of Dogs: 11
Name: NANCY CHAPMAN Kennel Name: CHAPMAN KENNELS
Mailing Address: 4201 W TIERRA BUENALN_ Kennel Address: SAME
City: PHOENIX State: AZ Zip: 85053
County Supervisorial District: 4
Phone: 623-910-6579 Kennel Phone: 623-910-6579
1. Are all dogs over the age of three months properly vaccinated for rabies and in
possession of a valid rabies vaccination certificate?
YES
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
NOTE: Copies of each rabies vaccination certificate must be attached to the Kennel Permit
Premise Inspection form.
CORRECTIVE ACTION NEEDED FOR COMPLIANCE AND N/A DAYS GIVEN
BEFORE REINSPECTION. (Note: There will be $49 re-inspect fee payable to the
Inspector by check upon each return visit.)
This is a RENEWAL application. There are 11 dogs on the property which are all properly
vaccinated for rabies and confined to the property under controlled conditions. There has
been no history of complaints/ violations at this residence.
Deputy Enforcement Agent & Badge #: Lt. Romero #4 Date: 8/18/2020
October 2015
CERTIFICATE OF VACCINATION
—
Date of Rabies Vaccination: 06-11-20
Next Rabies Vaccination On: 06-11-21
VETERINARY CLINIC
Sunburst Animal Hospital
13807 North 51st Avenue, Suite A
Glendale, AZ 85306
602-938-1860
This is to certify...
Certificate No: 0
Previous Rabies Vaccination:
OWNER OF ANIMAL
Nancy Chapman
4201 W Tierra Buena Ln
Phoenix, AZ 85053
County:
THAT | HAVE VACCINATED AGAINST RABIES THE ANIMAL DESCRIBED BELOW.
Patient information...
PATIENT: Lacy
SPECIES: Canine (Poodie)
SEX: F
Color and markings... White
Rabies Vaccine Information...
TAG NO:
WEIGHT: 33.25
AGE: 6 months
MICROCHIP: 985141002305998
MFG BY: MERI SER,NO: 18461 LO#EXP: 12/12/21 ADM: SQ
Signed
Tierney Coats, DVM
License: AZ7218
OWNER'S Copy
RABIES VACCINATION CERTIFICATE
NASPHY Form #51 Rabies Tag Number
Owner's Name and Address rint - use ball Point pen or type
PRINT - La First Teleph
~4J0-8 5 79
3 mo to 12 mo 1] y
Cat
Inder 20 Ibs;
12 mo or older 20 - 50 Ig, a
? O1] Neutered O} Actuat A Por Over 50 Ibs.
pects) " yr Actual. .
DATE VACCINATED:
2.
Month Day Year
(First 3 letters)
A yr. Lic’ Vace.
yr. Lic./ Vace,
———_—. Other
372529 4
Vace. Serial (lot) no.
VACCINATION EXPIRED:
2 2) 23
Month Day Year
er
Rabies Tag Numb
iN:
VAC CN ee mm #51
ov RABIES NASPHV ro pen
OWNER'S COF int - use ball P
aves Pri First
A
nd
Owner's Name 2!
@
Predominant Breed:
3 mo to 12 mo
42 mo or older
Cat
ther. Neutered O
Other:
(Gpecity)
er:
D: Produc
GCINATE!
DATE VA‘
2. 22°
r
Month Day Xe
(First letters) ‘Gignature)
Address:
Fonpe f 30
1, Lic./ Vace-
Other
aa
Vacc. Serial (lot) no.
ED:
VACCINATION EXPIA
Month Day Yea
OWE!
nS: GORY RABIES VACCINATION CERTIFICATE
NASPHV Form #517 Rabies Tag Number
Owner’s Name and Address Print - use ball point pen or type
PRINT - Last First Ml. | Telephone
Chapel, Mines _ 60AnfGb—*72I9
No. “Street, 7 ity Stat i
ydof We Terra fers fis Liber’
Species: ,| Sex: 4 Age: Size: | Predominant Breed” Colors:
Dog Male 3 mo to 12 mo [1 | Under 20 Ibs. ( f OL,
Cat ([1|Female [1] 12 mo or old of 20 - 50 Ibs. aB|KA parle GOK ube
Other: (| Neutered [1 | Actual noe’ Over 50 Ibs. 1
(Specify) Name:
Actual O-Ibs. : ff
Egy
DATE VACCINATED: Producer: 2 0 £ Veterinarian’s: # Tasman
_) Jo J4 nas De Tore) LY
Month Day Year [1p LicyVace. (Signature)
i Address: v fe / Yk 5;
VACCINATION EXPIRED: 33 ve wv Bes I. poe )
_) 10 2+ 293/26
Month Day Year Vacc. Serial (lot) no.
OWNER'S COPY RABIES VACCINATION CERTIFICATE
NASPHV Form #51
Print - use ball point pen or type
First
Rabies Tag Number
Lesa Ap. ASS) |
Owner's Name and Address
Age:
3 mo to 12 mo C1 | Under 20 Ibs-
“pf | 20 - 50 Ibs.
Cat
Other: 0
(Specify)
inarian’s: #
Veterinaria Ticense N
rome 205 Fu [STASI
Toopie, Aa F520]
DATE VACCINATED:
Producer: | ajols|
First 3 letters)
G
Month Day Year
011 yr. Lic./Vacc.
in) yr. Lic./Vacc.
Other
__ 293/H
Vacc. Serial (lot) no.
VACCINATION EXPIRED:
Month Day Year
OWNER'S GOPY
Owner’s Name and Address
RABIES VACCINATION CERTIFICATE
NASPHV Form #51
Print - use ball point pen or type
Rabies Tag Number
PRINT - Last
(a Cpmees)
Maw; Yy
First
Ml.
60]
Telephone
b—-IF6-Y 0/9
Street
° flo} WW
Dh erre Bi Cra
City
Phrewrx A 2 Pos?
Species: | Sex:
Dog Se Male oO
Cat (C1| Female
Other: [1 | Neutered 1
(Specify)
12 mo or older.
Actual Age,
Age: Size:
3 mo to 12 mo [1 } Under 20 bs
20 - 50 Ibs.
Over 50 Ibs. 11
Actual/ 2. S'ibs.
oO
Predominant Breed:
en’ shelby
Colors: ,
A
ke, ty (LIAU Led uhh
DATE VACCINATED:
jd. _ JS 79.
Month Day Year
VACCINATION EXPIRED:
(2 /S 20
am
Producer:| “~) eC E
111 yr. Lic./Vacc.
Ba:<) yr. Lic./Vacc.
Other
ZIV GLC
(First 3 letters)
Month Day Year
Vacc. Serial (lot) no.
Veterinarian’s: #
le ee
(License No.)
wmkS
Address: Be icalion
AxFS1y
OWNER'S COPY
Owner's Name and Address
RABIES VACCINATION CERTIFICATE
NASPHV Form #51
Print - use ball point pen or type
Rabies Tag Number
PRINT - First M.l. | Telephone
Eh. epmens, Maney bat b> 4019
Street Ci
25) in Herre. & Ruent Lad Lhoerr,d pits FLES3
Species: , | Sex: Age: Size: Predominant Breéd: Colors:
Dog Male
Cat (1| Female
3 mo to 12 mo [1] | Under 20 ibs.
1s L Charles G
12 mo or older 20-50 lbs. O
Other: [1 } Neutered (1 | Actual Age. Over 50 Ibs. Ay 4 } 2.
(Specify) Actual ibs. Name: Fa
& ite | tL
DATE VACCINATED: Producer: J. ro) A og Veterinarian’s: # V5) 5 a
Lo ad Oy. konto
Month Day Yea
VACCINATION EXPIRED:
) yo 22
Month Day Year
11 yr. Lic./Vace.
3 yr. Lic./Vacc.
Other
AGIA
Vacc. Serial (lot) no.
(Gignattire)
min BOSE.
Jonge,
A reF $25)
ISK SK
RABIES VACCINATION CERTIFICATE
Specify)
4 42 mo or older C1
Other: [| Neutered [1 | Actual Age.
[- OWNER’S COPY
NASPHV Form #51 Rabies Tag Number
Owner's Name and Address Print - use ball point pen or type Z.
PRINT - La kK First Ml. telephone
fe 4 C
op mars Narety 623-4104 6524
No. treet » it te, i
29) l/s Terre BUS be Glen PEA
Species: , | Sex: Age: Size: of Pret inant Breed:
Dog 4 Male (]3 mo to 12 moWA| Under 20 Ibs. ‘ ‘ G J
Cat Female - 50 Ibs. Kikg Co Ca
DATE VACCINATED:
Dd 2 20
Month Day Year
Producer:
VACCINATION EXPIRED;
a»
C13 yr. Lic./Vace.
Vacc. Serial (lot) no.
si
Other
wh
Address: 325
LL _|
signature) j
IA ST.
Tonge MESSE)
OWNER’S COPY
Owner's Name and Address
RABIES VACCINATION CERTIFICATE
NASPHV Form #51
Print - use ball point pen or type
Rabies Tag Number
PRINT Che pray, Mars
First
Telephon
(53490-6579
TZ : =
20) Pv ferra Burm ra
Glerdal@A ¥S033!
Species: || Sex: Age:
Dog Male
Cat Female 42 mo or olde!
(Specify)
3 mo to 12 mo BY Under 20 Ibs. C1
Other: (| Neutered [1 | Actual OT. Over 50 Ibs. 11
mm
Size:
+11) 20-50 lbs. O
Actual. Ibs.
Predominant eC,
Colors:
Livy LG) J —
Name: Gidg an
DATE VACCINATED:
poascer|2_| 0] E
_2. 2) 20
Month Day Year
VACCINATION EXPIRED:
2H» 2) ze
Month Day Year
ht yr. Lic./Vace.
(13 yr. Lic./Vace.
Vacc. Serial (lot) no.
(First 3 letters)
Other
PE
“ A2s//
Veterinarian’s: #
(License No.)
‘Gighature)
Address: 32 E. SHAst.
Zoope, Ar F52§)
OWNER'S COPY
Owner's Name ai dress
RABIES VACCINATION CERTIFICATE
NASPHV Form #51
Print - use ball point pen or type
Rabies Tag Number
PRINT - La
Che pre Masey/
First
Telephon
ML.
lorryg S40/9
*° u20) eT,
a
Ci
erra Dueng bw oY
Kher hci
Species: | Sex:
Specify)
Age: Size:
Dog [1] Male (| 3 mo to 12 mo Under 20 ibs
Cat 1/Female [1] 12 mo orolder§Q | 2050 Ibs.
Other: [1 | Neutered 1 | Actual hafyy- Over 5 . oO
nt Bg, i her
Colors:
fe
DATE VACCINATED:
_) jo j4
Month Day Year
10
Month ae ar
VACCINATION EXPIRED:
Producer: 2 Pia
yr. Lic./Vace.
Other
293/24
Vacc. Serial (lot) no.
Veterin st
(License No.)
D4. iy Lawl
(Signature)
OWNER’S COPY
Owner’s Name and Address
RABIES VACGINATION CERTIFICATE
NASPHV Form #51
Print - use ball point pen or type
Rabies Tag Number
PRINT - Las} F First
Ch Gyan Maney
any prea7 |v
Noo) Me ner Biers La”
Clezidale Be FSIOS3
Species:., | Sex:
Dog Male oO
Cat (| Female
Other: [| Neutered C1
(Specify)
Age: Size:
3 mo to 12 dee Under 20 ins
42 mo or olde 20-50lbs. O
Actual Aee Joy Over 50 Ibs. 0
Actual_){)- Ibs.
Uv
Predominant Breed: Coloys:
Rika Gs Ca. Ble. 271)
Name: Jory’ —
DATE VACCINATED:
(2. 2) 20
Month Day Year
VACCINATION EXPIRED:
2 2) 2)
Producer: 2 ) is
(First 3 letters)
wh yr. Lic./Vacc.
013 yr. Lic./Vace.
Other
37292941
Month Day Year
Vacc. Serial (lot) no.
Veterinarian’s: # 20 J)
(License No.) Wi
Qa» Fell
(Signature)
Address: 3 2S = a] 5 a7 SA
Tange, H2- G28)
OWNER'S COBY, RABIES VACCINATION CERTIFICATE
; NASPHV Form #51 Rabies Tag Numbe!
Owner’s Name and Address Print - use ball point pen or type
PRINT - bast First 1. | Teley
r apne Marey baasy ibe 40/9
° 20) We frcrra Burra Zn Phere fe KOS
Species: | Sex: Size: a :
Dog [1] Male oO Under 20 tbs
Cat []|Female [1] 12 moor olde 20-50 lbs. O
Other: C1 | Neutered (1 | Actual Age | Over 50 Ibs.
(Specify) Thy Actual a Name: ry tT
OMNe
NX
pare aconaren: Joroacee| 16 [£ | — [wtenatanve L227 T°
) J0 79 | aie (First 3 letters) “Don Fm or MD) Lc
1
Month Di Ye
jay ear yr. Lic./Vace.
VACCINATION EXPIRED‘ Dts yx. -_* as Ax S. )
——__ r ¢. e eo DF)
alo 293/26 ad
Monin ya Year Vacc. Serial (lot) no.
(Signature)
OWNER'S COP’ RABIES VACCINATION CERTIFICATE
NASPHV Form #51 Rabies Tag Number
Owner’s Name and Address Print - use ball point pen or type
PRINT - La: First Telephone
pron) Maney "CRF H— "0/9
Ne 130] "Wa Wa Herre | Boerne bak Phoenii AE Froks
Species: | Sex: Age: Size: Predominant Breed: Colors:
} , ae
Dog ‘A Male F4 3 mo to 12 mo CJ | Under 20 Ibs. Ki, Zh cles Cc pred fukte
Cat [|Female [1] 12moorolder (| 20-50lbs. O
Other: (1 | Neutered C1 | Actual A8°-Faige Over 50 Ibs. 11
nee) Actual {5 Ibs, | Name: [
f has
DATE VACCINATED: Producer: 2 fe) aie Veterinarian’s: # Fizs aa
10 1G (First 3 letters) : D4» Face ‘ad
Month Day Year , jignature)
111 yr. Lic./Vace. Floss JS fF. / SK Y,
Des yr. Lic./Vacc,
VAGGINATION EXPIRED: Bike Fnge, A paar
19 22
Month Day Year Vacc. Serial (lot) no.
Fesgenore, Mare
omenscor” RABIES VACCINATION CERTIFICATE
NASPHV Form #51 Rabies Tag Number
Owner’s —_ and Address Print - use ball point pen or type
PRINT - First Telephone
wer LPF 1019
NO 0) [ae Be pre
ony Ihoena Az.
LiFe
ae AL 0 If Zip
Species: _ | Sex:
Cat [L1| Female
Other: [1 | Neutered
Age: Size:
Dog i Male 1] 3 mo to ed Under 20 Ibs. A. A jf. Tau ( ras Jha Te
12 mo or older.
a4 Actual Age Over 50 Ibs.
(Specify) ¥ Name:
MO
Predominant Breed:
20-50 lbs. C1
Actual Ibs.
Colors:
DATE VACCINATED: Proucer| 2 | O Veterinarian's: # 122 227 __
4)
M2 LS +7 (First 3 letters) La, Frown x bel!
Month: Day’ “Year 11 yr. Lic/Vace. (ignature)
CINATION EXPIRED: 8 vrbie Veco: mowers 395 £-1F: wk SK
VACCINA' : a
oth
7 _ Hersh 2-65.
12,15 20 219) 92¢
Month Day Year
Vacc. Serial (lot) no.
OWNER'S COPY
RABIES VACCINATION CERTIFICATE
NASPHV Form #57
Rabies a
Owner's Name and Address Print - use ball point pen or type
PRINT - on First Ml. | Telephoné
Chepmaw, Mapey Coit JH-Y019
No. Street
co Buena
iad ffreses 2 FLO ei
Species: | Sex:
Dog -z Male Oo
Cat (1| Female
(Specify)
Size: Predo inet Br Breed:
Under 20 Ibs. (1
a4 es Ibs. Keipvey C2 Cary. ls
Other: [1 | Neutered C1 | Actual Agedy,— Over.50 Ibs¢
ActualZ-O. Ibs. Name: / eo, cl’
Colors:
ace bie é
DATE VACCINATED:
12 6 17
Month Day Year
VACCINATION EXB!
. | Veterinarian’s: # AL) LIF4 —
Producer: a) E 7 5 ‘+ z
(First 3 letters) = Z sy
fe
Mle lV
ignatur)
(11 yr. Lic./Vace.
yr. Lic./ Vacc.
Address: KPA Se
—_______ Other
212/920 Ferepit,
Vacc. Serial (lot) no.