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c!TY <br /> According to the Paperwork Reduction Act of 1995,no persons are required to respond to a collection of FORM APPROVED OMB NO.:0579-0036 <br /> information unless it displays a valid OMB control number.The valid OMB control number for this information <br /> collection is 0579-0036.The lime required to complete this information collection is estimated to average.25 hours No license may be issued unless a completed application has been received(7 U.S.C.2132-2143), <br /> per <br /> response.including the time for reviewing Instructions,searching existing data sources,gathering and and the applicant is in compliance with the standards and regulations Section 2133. <br /> maintaining the date needed,and completing and reviewing the collection of information. <br /> U.S.DEPARTMENTOF AGRICULTURE DO NOT USE THIS SPACE-OFFICIALUSE ONLY <br /> ANIMAL AND PLANT HEALTH INSPECTION SERVICE <br /> SEND THE COMPLETED FORM TO: <br /> APPLICATION FOR LICENSE USDA R gISANIMAL CARE <br /> Weste(TYPE OR PRINT) 2150 Centre Ave. <br /> Building B,Mailstop 3W)) <br /> X RENEWAL Fort Collins,CO 80526-8117 <br /> (970)494-7478 <br /> LICENSE NO./COST NO RENEWAL DATE FEES <br /> 91-C-0104 26-May-2016 AMOUNT DATE RECEIVED <br /> 32737 <br /> 1. NAME(S)OF OWNER(S)AND MAILING ADDRESS 2. ALL BUSINESS NAME,LOCATIONS,AND ALL SITES HOUSING ANIMALS(P.O.Box not <br /> City Of Everett acceptable) <br /> Parks&Recreation Dept. 802 E.Mukilteo Blvd. <br /> 802 E.Mukilteo Blvd. Everett,WA 98203 <br /> Everett,WA 98203 County:Snohomish TELEPHONE (415.0,15/-93Oo <br /> COUNTY: Snohomish TELEPHONE (425)257-8300 F <br /> 3. IF PREVIOUSLY LICENSED-NAME AND ADDRESS 4. NAME AND ADDRESS OF OTHER BUSINESS(S)HANDLING ANIMALS IN WHICH <br /> GiT"; er 0 s,' X,e F `YIGr> � APPLICANT/LICENSEE HAS AN INTEREST <br /> PREVIOUS LICENSE NO.: / I -C'7 -o i L4 <br /> 5. TYPE OF LICENSE 6. DATE OF LAST BUSINESS YEAR <br /> ❑A-Dealer(Breeder) 0 B—Dealer O C-Exhibitor FROM TO <br /> 7. NATURE OF BUSINESS(Check item that describes nature of your business) MO DAY YEAR MO DAY YEAR <br /> Al A—Zoo ❑ B-Aquariums ❑C—Auction <br /> 0 5 2 6 1 5 0 5 2 5 1 6 <br /> ❑ D—Breeder D E—Pets ❑ F—Roadside Zoo <br /> 8. TYPE OF ORGANIZATION <br /> 0 G—Circus ❑H—Animal Acts 0 I—Carnival O Partnership 0 Corporation 0 Individual <br /> R Other(Specify) l,1 irj -- Ali)Afk'-/PH-C_ 6OU leki <br /> ❑J—Drive thru 0 K—Pet Store 0 L-Broker <br /> Zoo <br /> 9. LIST OWNERS,PARTNERS,AND OFFICERS <br /> NAME AND TITLE ADDRESS <br /> t,i'lL7Pf x:s,r5.1-N— 16C gba r, hi UL i L7ez, 6 c_Ub <br /> 6UmAll 1' S — P Ks DIO <br /> 66o Pax teMe??-76,0 Gi)0,eD OVekerr WA 9V,;/'� <br /> --1476 -T (, 2-IZcz ? TO 3 EvfPU <br /> 10. DEALER ONLY 11. EXHIBITOR ONLY(No.of animals holding now or held during the last business year,whichever is <br /> greater) <br /> TOTAL NO.OF ANIMALS PURCHASED IN THE LAST <br /> BUSINESS YEAR DOGS RABBITS .. <br /> TOTAL NO.OF ANIMALS SOLD IN THE LAST �jJ <br /> BUSINESS YEAR CATS NONHUMAN PRIMATES <br /> TOTAL GROSS AMOUNT DERIVED FROM THE SALE <br /> OF ANIMALS GUINEA PIGS MARINE MAMMALS <br /> WILD OR EXOTIC <br /> DOLLAR AMOUNT OF WHICH FEE IS BASED �-K/HAMSTERS MAMS, �y <br /> (Sections 2.6 and 2.7) OTHER(i.e.,farm animals)(List r r`-" ) �E. <br /> Species and No. jJes7--Op14.5 n _ �Y <br /> CERTIFICATION <br /> I hereby make application for a license under the Animal Welfare Act 7 U.S.C.2131 et seq. I certify that the information provided herein is true <br /> and correct to the best of my .nowledge. I hereby acknowledge receipt of and certify to the best of my knowledge I am in compliance with all <br /> regulations and standards in FR,Subpart A,Parts 1,2,and 3. I certify that I am over 18 years of age. <br /> c. <br /> SIGNATURE 13. NAME AND TITLE(Type or Print) 14. D TE <br /> A HIS FORM 7003 �� <br /> ` (Previous editions are obsoletetil <br /> ) l <br /> (JAN 1995) <br /> ' ST: <br /> ATI _.._ . <br /> DYI ' rOrn,ev <br /> 61 �......a.•� <br /> City Jerk <br />