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AGENCY <br /> According to the Peponvork Reduction AU of 1905,no persons aro required to respond too collodion of FORM APPROVED OMB NO.:0579-0036 <br /> information unless It displays a valid ONE control number.Tho void OtaB control number for this information <br /> co <br /> ction Is <br /> 79-0036.The <br /> uired to <br /> informa <br /> ion collodion <br /> parrrrocporoo Including the time for ovwwmg instructions.taoarchingt mooting data ooursoD,goostimoted lf 25 hero No license may be issued unless a completed application has been received(7 U.S.C.2132.2143), <br /> mnnlninInn tan data hooded,and no rplrmnrl and mvl,whp!ha coancllnn at lornrmnllon and the applicant is in compliance with the standards and regulations Section 2133, <br /> U.S.DEPARTMENTOF AGRICULTURE <br /> ANIMAL AND PLANT HEALTH INSPECTION SERVICE DO NOT USE THIS SPACE-OFFICIALUSE ONLY <br /> SEND THE COMPLETED FORM TO: <br /> APPLICATION FOR LICENSE USDA RPNISANIMAL CARE <br /> (TYPE OR PRINT) 2150 Centre Ave. <br /> Building B,Mailstop 3W1 I <br /> X RENEWAL Fort Collins,CO 80526-8117 <br /> (970)494-7478 <br /> LICENSE NOJCUST NO RENEWAL DATE FEES <br /> 91-C-0104 26-May-2017 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.0.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 95203 County:Snohomish TELEPHONE (4 '), 7—g3c <br /> COUNTY: SNOHOMISH TELEPHONE(425)257-8300 <br /> 3. IF PREVIOUSLY LICENSED-NAME AND ADDRESS',.' 4.NAME AND ADDRESS OF OTHER BUSINESS(S)HANDLING ANIMALS IN WHICH <br /> 671 c CVL I?E�7 pAt 1 zezec tz:t APPLICANT/LICENSEE HAS AN INTEREST <br /> PREVIOUS LICENSE NO.: 4I—'�T.— /o4 <br /> S.TYPE OF LICENSE 6.DATE OF LAST BUSINESS YEAR <br /> 0 A-Dealer(Breeder) e B—Dealer •C-Exhibitor FROM TO <br /> 7. NATURE OF BUSINESS(Chock item that describes nature of your business) MO DAY YEAR MO DAY YEAR <br /> 'It A—Zoo ❑ B-Aquariums ❑C—Auction <br /> 0 5 1 to 1 0 5 Z-. � 1 8 <br /> ❑D—Breeder 0 E—Pets 0 F—Roadside Zoo <br /> 8.TYPE OF ORGANIZATION <br /> ❑G-Circus ❑H—Animal Acts 0 I—Carnival o Partnership 0 Corporation 0 Individual <br /> • Other(Specify)`17.7 rh U%Lc W.:„Piht. aI JYfle f0j <br /> ❑J—Drive thru ❑K—Pet Store 0 L-Broker <br /> Zoo <br /> 9. LIST OWNERS,PARTNERS,AND OFFICERS <br /> NAME AND TITLE ADDRESS <br /> Padri— P4-64-3S��U — h1' — kin-C5 j3(.-v b <br /> +&v mrnAS-GS -SKS D) 7b2.. 63V05 <br /> 10. DEALER ONLY 11. EXHIBITOR ONLY(No.of animals holding now or hold during the last business year.whichever is <br /> greater) <br /> TOTAL NO.OF ANIMALS PURCHASED IN THE LAST <br /> BUSINESS YEAR DOGS RABBITS ��cr <br /> 4/n <br /> TOTAL NO.OF ANIMALS SOLD IN THE LAST 401.,"( <br /> m�+—7` <br /> BUSINESS YEAR +TcR NONHUMAN PRIMATES <br /> TOTAL GROSS AMOUNT DERIVED FROM THE SALE 'F-Ai ?" <br /> OF ANIMALS ZOOM PIGS .f MARINE MAMMALS <br /> vntiT�2— c;.. <br /> WILD OR EXOTIC <br /> DOLLAR AMOUNT OF WHICH FEE IS BASED� ��MAMMALS <br /> (Sections Z6 and 2.7) OTHER(1.e.,farm animals)(List TOTAL: <br /> Species and No.).1 ) <br /> • <br /> CERTIFICATION <br /> 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 knowledge. I hereby acknowledge receipt of and certify to the best of my knowledge I am in compliance with all <br /> regulations and st dards in CFR,Subpart A,Parts 1,2,and 3. I certify that)am over 18 years of age. <br /> 12. SIGN po,E 13. NAME AND TITLE(Typo or Print) I 14. DATE <br /> APHIS FOR 03 (Previous editions are obsolete) 141 �,7 <br /> (JAN 1995) D <br /> A ST: AP OVED AS 0 F M <br /> City Clerk JAMES D.ILES,City Attorney <br />