5120GOVERNMENT GAZETTE, WA 15 November 2016

5120 GOVERNMENT GAZETTE, WA 15 November 2016 E-mail address ............................................................................................................................................. Apply for a licence for an approved kennel establishment at (address of premises) ................................ ......................................................................................... for (number and breed of dogs) ..........................

• (insert name of person) .............................................................................................................................. will be residing at the premises on and from (insert date) .......................................................................
• (insert name of person) .............................................................................................................................. will be residing (sufficiently close to the premises so as to control the dogs and so as to ensure their health and welfare) at (insert address of residence) .................................................................................... on and from (insert date) .............................................................. Attached are— (a) a site plan of the premises showing the location of the kennels and yards and all other buildings and structures and fences; (b) plans and specifications of the kennel establishment; (c) copy of notice of proposed use to appear in newspaper; (d) copy of notice of proposed use to be given to adjoining premises; (e) written evidence that a person will reside— (i) at the premises; or (ii) sufficiently close to the premises so as to control the dogs and so as to ensure their health and welfare; and (f) if the person in item (e) is not the applicant, written evidence that the person is a person in charge of the dogs. I confirm that I have read and agree to comply with the Code of Practice known as................................ ................................................................. in the keeping of dogs at the proposed kennel establishment. Signature of applicant ............................................................................. Date .........................................
• delete where not applicable Note: A licence if issued will have effect for a period of 12 months—section 27(5) of the Dog Act 1976. OFFICE USE ONLY Application fee paid (insert date) ......................................................................... ————