3816GOVERNMENT GAZETTE, WA 29 October 2019

3816 GOVERNMENT GAZETTE, WA 29 October 2019 SCHEDULE 1—APPLICATION FOR A LICENCE FOR A DESIGNATED [clause 4.2] APPLICANT/S DETAILS Name of Applicant/s (in full)......................................................................................................................... Residential Address ...................................................................................................................................... ................................................................................................ (Suburb) Post Code……......………………… Postal Address (if different from above) ....................................................................................................................................................................... Telephone (Home)……………………… (Work)……..………………… (Mobile) ............................................ Email ............................................................................... Fax ................................................................................... CAT MANAGEMENT FACILITY DETAILS I/ We apply for a licence for a designated cat management facility at: Address of premises ....................................................................................................................................................................... ................................................................................................ (Suburb) Post Code……......………………… For number of cats ……………………………… Person will reside (tick appropriate box) *evidence to be provided —   at the premises    sufficiently close to the premises so as to control the cats and so as to ensure their health and welfare  Name of person (if not applicant/s) Address of residence (if not residing at the premises) ....................................................................................................................................................................... ....................................................................................................................................................................... Prior to approval the following must be attached— (a) a site plan of the premises showing the location of the cages and runs and all other building and structures and fences; (b) plans and specifications of the Cat Management Facility; (c) proposed details of how the facility will be kept secure; (d) evidence that a person will reside— (i) at the premises; or (ii) sufficiently close to the premises so as to control the cats and so as to ensure their health and welfare; and (iii) if the person in item (d) is not the applicant, evidence that the person is a person in charge of the cats. Signature of applicant………………………………………………….… Date…………………………………………… Note: A licence, if issued, will have effect for a period of 12 months, effective from the date of issue unless and until it is revoked or it is determined by the local government non-compliance with the conditions of the Shire of Northam Cat Local Law 2019 justifies this. ———— APPLICATION FEE Cat Management Facility Establishment Fee $200.00 OFFICE USE ONLY Application No. ...................................................... Date…………/…………/………… Receipt No. ............................................................ Amount Paid........................................................... Cashier ...................................................................