4044GOVERNMENT GAZETTE, WA 21 September 2016

4044 GOVERNMENT GAZETTE, WA 21 September 2016 SCHEDULE 1—APPLICATION FOR A LICENCE FOR AN APPROVED KENNEL ESTABLISHMENT (clause 4.2) I/we (full name) ............................................................................................................................................. of (postal address) ......................................................................................................................................... (telephone number) ....................................................................................................................................... (facsimile number) ........................................................................................................................................ (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 ...............................................................................................