US Dept of Agriculture 4/24/2017

CITY According to the Paperwork Reduction Act of 1995,no persons are required to respond to a collection of FORM APPROVED OMB NO.:0579-0036 information unless it displays a valid OMB control number.The valid OMB control number for this information,, collection is 0579-0036.The time 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), per 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. maintaining the date needed,and completing and reviewing the collection of information. U.S.DEPARTMENTOF AGRICULTURE ANIMAL AND PLANT HEALTH INSPECTION SERVICE DO NOT USE THIS SPACE-OFFICIALUSE ONLY SEND THE COMPLETED FORM TO: APPLICATION FOR LICENSE U sA RN IS ANIMAL CARE W(TYPE OR PRINT) 2150 Centre Ave. Building B,Mailstop 3W1 I X RENEWAL Fort Collins,CO 80526-8117 (970)494-7478 LICENSE NO.ICUST NO RENEWAL DATE FEES 91-C-0104 26-May-2017 AMOUNT DATE RECEIVED 32737 1. NAME(S)OF OWNER(S)AND MAILING ADDRESS 2. ALL BUSINESS NAME,LOCATIONS,AND ALL SITES HOUSING ANIMALS(P.O.Box not City Of Everett acceptable) Parks&Recreation Dept. 802 E.Mukilteo Blvd. 802 E.Mukilteo Blvd. Everett,WA 98203 Everett,WA 98203 County:Snohomish TELEPHONE (42.5").?57-R300 COUNTY: SNOHOMISH TELEPHONE (425)257-8300 3. IF PREVIOUSLY LICENSED-NAME AND ADDRESS �I/.�,,-r� 4. NAME AND ADDRESS OF OTHER BUSINESS(S)HANDLING ANIMALS IN WHICH Crr7 D=Cve-ze t/�'� f 5 f iZr-6`c-TI�1606 DcAPPLICANT/LICENSEE HAS AN INTEREST PREVIOUS LICENSE NO.: 7 l ^ —D/e)4 5. TYPE OF LICENSE 6. DATE OF LAST BUSINESS YEAR o A-Dealer(Breeder) 0 B—Dealer o C-Exhibitor FROM TO 7. NATURE OF BUSINESS(Check item that describes nature of your business) MO DAY YEAR MO DAY YEAR "k A-Zoo ❑ B-Aquariums ❑ C-Auction 0 5 1 Yo 1 1 0 5 1,, I ❑ D-Breeder ❑ E-Pets ❑ F-Roadside Zoo 8. TYPE OF ORGANIZATION ❑G-Circus 0 H-Animal Acts ❑ I-Carnival 0 Partnership 0 Corporation 0 Individual 6 Other(Specify)6•/ ❑J-Drive thru ❑ K-Pet Store ❑ L-Broker T r — )?4 U,,,,,, fit. C OVe itIm�NIJ Zoo 9. LIST OWNERS,PARTNERS,AND OFFICERS NAME AND TITLE ADDRESS LoT TcP+f-ttx3 54L. - N1' ele_- 9-_)z_ C-- )44-(Y 4 L-1-&-O tC 3 CAt &0 hi,iiA s - -SKS 1 ,I gez-rdTC... eiZ rr 63V05 _ t ----t- I - 1'Fr=ee s c,Fv 10. DEALER ONLY 11. EXHIBITOR ONLY(No.of animals holding now or held during the last business year,whichever is greater) TOTAL NO.OF ANIMALS PURCHASED IN THE LAST BUSINESS YEAR DOGS RABBITS ..46e TOTAL NO.OF ANIMALS SOLD IN THE LAST 'i Miti BUSINESS YEAR 0 NONHUMAN PRIMATES TOTAL GROSS AMOUNT DERIVED FROM THE SALE '-+ -> -i _)LIrL14..Ln OF ANIMALS 1011.111 PIGS a MARINE MAMMALS 14r 1c3Ut ryzTt1,L_,5 ✓C WILD OR EXOTIC DOLLAR AMOUNT OF WHICH FEE IS BASED 5(R _ /a�MAMMALS ier (Sections 2.6 and 2.7) OTHER(i.e.,farm animals)(List TOTAL: �^ Species and No.,4-��r a J CERTIFICATION v, 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 and correct to the best of my knowledge. I hereby acknowledge receipt of and certify to the best of my knowledge I am in compliance with all regulations and standards in 9 CFR,Subpart A,Parts 1,2,and 3. I certify that I am over 18 years of age. 1 Ie ATUR ---- I 13. NAME AND TITLE(Type or Print) 14. D TE � , , / i, APHIS 01-M 701 (Previous editions are obsolete) (JAN 1'• ) A T , T. AT / \OVED ' JO :;j M City Clerk rf .i'r��.' `J JAMES DAIS,City A torney