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MC-11-47
Inspection Number: INSP - 154770 Permit Number: MC -1 -11-47 Scheduled Inspection Date: January 27, 2011 Inspector: Perez, JanPierre Owner: CHURCH, ST ROSE OF LIMA CATHOLIC Job Address: 418 NE 105 Street Project: <NONE> January 26, 2011 Miami Shores, FL Contractor: MODERN MIDWAYS Building Department Comments Inspection Worksheet Miami Shores Village 10050 N.E. 2nd Avenue Miami Shores, FL Phone: (305)795 -2204 Fax: (305)756 -8972 TEMPORARY FOR AMUSEMENT RIDES AT CHURCH CARNIVAL JAN 2830 2011 Passed D Failed Correction Needed Re- Inspection Fee No Additional Inspections can be scheduled until re- inspection fee is paid. Inspector Comments it on, t For Inspections please call: (305)762 -4949 U Permit Type: Mechanical - Commercial Inspection Type: Final Work Classification: New Phone Number (305)758 -0539 Parcel Number 1122310150060 Phone: (305)234 -7776 Page 13 of 29 CHARLES H. BRONSON COMMISSIONER DATA: Date Inspector Event Location KIDDIE NON - KIDDIE SUPER REQUIREMENTS: (Check each requirement as it is accomplished or place (N) if not applicable) 1. RIDE STATUS a.( ) Permit b.( ) Insurance c.( ) Compliance /NDT d.( ) Manuals 4. ATTACHMENTS a.4 Gen Attachments b.(✓J arrier/Tubs c.(. Restraints d. (r9'Sweeps DEFICIENCIES: / . 2 ;r ) 4i/' / RESULTS: DACS -03419 Rev. 12/09 Florida Department of Agriculture and Consumer Services Bureau of Fair Rides Inspection AMUSEMENT RIDE INSPECTION REPORT Ride Owner + t- Ride Name <, MFG /�- -/ Co /j'�' < / Serial # USAID # Permit # n. .4, White /Bureau Section 616.242(4), Florida Statutes Rule 5F- 8.0012, Florida Administrative Code Phone (850) 488 -9790; Fax (850) 488 -9023 2. INSTALLATION a. Blocking b.() Fencing /Guarding c.(1 Braces /Guys /Anchors d.() Signs e.( -') Electrical 5. OPERATION a.(..) RPM Check b.(, Controls c.( 1 Brakes d.(') Limit Controls ,.� ✓, a-i . ,,.* e Canary/ Owner or Manager Pink/Event ScheduleUnannounced Re- inspection — Permit Inspection /Red Tag History Temporary — Permanent Location When Facing: L. 3. STRUCTURAL a.(kiydraulics /Pneumatics b.( Pins /Bolts /Keys c. (''Structural Integrity d. (Jires/Wheels /Casters e.(-1 Bearings /Spindles /Axles f. (.4 Iron 6. OTHER a.( ) Automatic Sprinkler /Smoke Detector b.(-) Water Quality c.(4Bungy Cords d.(4.Cranes e.( y ' Comments Inspection R. /.-" `%,d PURSUANT TO Section 616.242(7), F.S., AN INSPECTION CERTIFICATE IS ISSUED, when box is checked. The above identified amusement ride meets the requirements of Section 616.242, F.S. and Chapter 5F -8, F.A.C. and the deficiencies noted above (if any) have been corrected. INSPECTION CERTFICATE (DACS 03550, Rev. 01/09) # / s' `` 5 )-" IB 1 acknowledge ride is §616.242(16), and the receipt of this inspection report and the NOTICE OF RIGHTS on the reverse side of this form. I certify this amusement in compliance with §616.242, F.S. The employee responsible for operating this ride has been trained in accordance with F.S. and the nufacturers operating instructions or the operating fact sheets for this ride are available to the operator, last 14 / daily ins ec on reports were completed and available upon request. (( { { ,: Owner/Manager Signatu . - ' Inspector's Signature PURSUANT TO Sec 616.242(7), F.S., the above identified amusement ride does not meet the requirements of Section 616.242, F.S. and Chapter 5F -8, F.A.C. and shall not operate until it passes a subsequent inspection by the Department. STOP OPERATION ORDER (DACS 03545, Rev. 01/09) # Owner/Manager Signature Inspector's Signature fe ] J CHARLES H. BRONSON COMMISSIONER DATA: Date Inspector Event Location KIDDIE NON - KIDDIE SUPER REQUIREMENTS: (Check each requirement as it is accomplished or place (N) if not applicable) 1. RIDE STATUS a.( ) Permit b.( ) Insurance c.( ) Compliance /NDT d.( ) Manuals 4. ATTACHMENTS a.4 Gen Attachments b.(✓J arrier/Tubs c.(. Restraints d. (r9'Sweeps DEFICIENCIES: / . 2 ;r ) 4i/' / RESULTS: DACS -03419 Rev. 12/09 Florida Department of Agriculture and Consumer Services Bureau of Fair Rides Inspection AMUSEMENT RIDE INSPECTION REPORT Ride Owner + t- Ride Name <, MFG /�- -/ Co /j'�' < / Serial # USAID # Permit # n. .4, White /Bureau Section 616.242(4), Florida Statutes Rule 5F- 8.0012, Florida Administrative Code Phone (850) 488 -9790; Fax (850) 488 -9023 2. INSTALLATION a. Blocking b.() Fencing /Guarding c.(1 Braces /Guys /Anchors d.() Signs e.( -') Electrical 5. OPERATION a.(..) RPM Check b.(, Controls c.( 1 Brakes d.(') Limit Controls ,.� ✓, a-i . ,,.* e Canary/ Owner or Manager Pink/Event ScheduleUnannounced Re- inspection — Permit Inspection /Red Tag History Temporary — Permanent Location When Facing: L. 3. STRUCTURAL a.(kiydraulics /Pneumatics b.( Pins /Bolts /Keys c. (''Structural Integrity d. (Jires/Wheels /Casters e.(-1 Bearings /Spindles /Axles f. (.4 Iron 6. OTHER a.( ) Automatic Sprinkler /Smoke Detector b.(-) Water Quality c.(4Bungy Cords d.(4.Cranes e.( y ' Comments Inspection R. /.-" `%,d DACS -03419 Rev. 01/09 Administrative Hearing Available If you wish to contest the Department's action, you have the right to request an administrative hearing to be conducted in accordance with Sections 120.569 and 120.57, Florida Statutes and to be represented by counsel or other qualified representative. Your request for hearing must contain: 1. Your name, address, and telephone number, and facsimile number (if any). 2. The name, address, and telephone number, and facsimile number of your attorney or qualified representative (if any) upon whom service of pleadings and other papers shall be made. 3. A statement that you are requesting an administrative hearing and dispute the material facts alleged by the department, in which case you must identify the material facts that are in dispute (formal hearing), or that you request an administrative hearing and that you do not dispute the facts alleged by the department (informal hearing). 4. A statement of when (date) you received this Notice and the file number of this Notice. Your request for a hearing must be received at the address shown on this Notice within twenty -one (21) days of receipt of this Notice. If you fail to obtain a Release from this Notice or fail to request an administrative hearing within the twenty -one (21) day deadline you waive your right to a hearing and the Department may enter a Final Order imposing up to the maximum penalties as authorized by Florida Law. I have read this notice of rights: SIGNATURE OF OWNER DATE CHARLES H. BRONSON COMMISSIONER DATA: Date Inspector Event Location /"T 1. RIDE STATUS a.( ) Permit b.( ) Insurance c.( ) Compliance /NDT d.( ) Manuals 4. ATTACHMENTS a.( ) Gen Attachments b.( ) Carrier/Tubs c.( ) Restraints d.( ) Sweeps DEFICIENCIES: ESULTS: DACS -03419 Rev. 12/09 Florida Department of Agriculture and Consumer Services Bureau of Fair Rides Inspection AMUSEMENT RIDE INSPECTION REPORT White /Bureau Section 616.242(4), Florida Statutes Rule 5F- 8.0012, Florida Administrative Code Phone (850) 488 -9790; Fax (850) 488 -9023 Ride Owner Ride Name MFG Serial # USAID # Permit # M 4.ra4. .. d r .., , ., c 9 {d y4 .7 wJ KIDDIE NON - KIDDIE SUPER REQUIREMENTS: (Check each requirement as it is accomplished or place (N) if not applicable) 2. INSTALLATION a.( Blocking b.( Fencing /Guarding c.( Braces /Guys /Anchors d.( Signs e.( Electrical 5. OPERATION a.( ) RPM Check b.( ) Controls c.( ) Brakes d.( ) Limit Controls s r w '� 3 Scheduled — Unannounce Re- inspection — Permit Inspection /Red Tag History 3-Temporary -- Permanent Location When Facing: L. R. 3. STRUCTURAL a.( Hydraulics /Pneumatics b.( ) Pins /Bolts /Keys c.( Structural Integrity d.( ).Tires/Wheels /Casters O e.( Bearings /Spindles /Axles f. (I) Track/Rim Iron 6. OTHER a.( ) Automatic Sprinkler /Smoke Detector b.( ) Water Quality c.( ) Bungy Cords d.( ) Cranes e.( ) Comments anary / Owner or Manager ink/Ev Inspection PURSUANT TO Section 616.242(7), F.S., AN INSPECTION CERTIFICATE IS ISSUED, when box is checked. The above identified amusement ride meets the requirements of Section 616.242, F.S. and Chapter 5F -8, F.A.C. and the deficiencies noted above (if any) have been corrected. INSPECTION CERTFICATE (DACS 03550, Rev. 01/09) #. , y=-ri' 4 r - ® I acknowledge ride is §616.242(16), and the receipt of this inspection report and the NOTICE OF RIGHTS on the reverse side of this form. I certify this amusement in compliance with §616.242, F.S. The employee responsible for operating this ride has been trained in accordance with F.S. and the manufacturers operating instructions or the operating fact sheets for this ride are available to the operator, last 14 daily inspection reports were completed and available upon request. Owner /Manager Signature Inspector's Signature PURSUANT TO Section 616.242(7), F.S., the above identified amusement ride does not meet the requirements of Section 616.242, F.S. and Chapter 5F -8, F.A.C. and shall not operate until it passes a subsequent inspection by the Department. STOP OPERATION ORDER (DACS 03545, Rev. 01/09) # Owner/Manager Signature Inspector's Signature CHARLES H. BRONSON COMMISSIONER DATA: Date Inspector Event Location /"T 1. RIDE STATUS a.( ) Permit b.( ) Insurance c.( ) Compliance /NDT d.( ) Manuals 4. ATTACHMENTS a.( ) Gen Attachments b.( ) Carrier/Tubs c.( ) Restraints d.( ) Sweeps DEFICIENCIES: ESULTS: DACS -03419 Rev. 12/09 Florida Department of Agriculture and Consumer Services Bureau of Fair Rides Inspection AMUSEMENT RIDE INSPECTION REPORT White /Bureau Section 616.242(4), Florida Statutes Rule 5F- 8.0012, Florida Administrative Code Phone (850) 488 -9790; Fax (850) 488 -9023 Ride Owner Ride Name MFG Serial # USAID # Permit # M 4.ra4. .. d r .., , ., c 9 {d y4 .7 wJ KIDDIE NON - KIDDIE SUPER REQUIREMENTS: (Check each requirement as it is accomplished or place (N) if not applicable) 2. INSTALLATION a.( Blocking b.( Fencing /Guarding c.( Braces /Guys /Anchors d.( Signs e.( Electrical 5. OPERATION a.( ) RPM Check b.( ) Controls c.( ) Brakes d.( ) Limit Controls s r w '� 3 Scheduled — Unannounce Re- inspection — Permit Inspection /Red Tag History 3-Temporary -- Permanent Location When Facing: L. R. 3. STRUCTURAL a.( Hydraulics /Pneumatics b.( ) Pins /Bolts /Keys c.( Structural Integrity d.( ).Tires/Wheels /Casters O e.( Bearings /Spindles /Axles f. (I) Track/Rim Iron 6. OTHER a.( ) Automatic Sprinkler /Smoke Detector b.( ) Water Quality c.( ) Bungy Cords d.( ) Cranes e.( ) Comments anary / Owner or Manager ink/Ev Inspection Administrative Hearing Available If you wish to contest the Department's action, you have the right to request an administrative hearing to be conducted in accordance with Sections 120.569 and 120.57, Florida Statutes and to be represented by counsel or other qualified representative. Your request for hearing must contain: 1. Your name, address, and telephone number, and facsimile number (if any). 2. The name, address, and telephone number, and facsimile number of your attorney or qualified representative (if any) upon whom service of pleadings and other papers shall be made. 3. A statement that you are requesting an administrative hearing and dispute the material facts alleged by the department, in which case you must identify the material facts that are in dispute (formal hearing), or that you request an administrative hearing and that you do not dispute the facts alleged by the department (informal hearing). 4. A statement of when (date) you received this Notice and the file number of this Notice. Your request for a hearing must be received at the address shown on this Notice within twenty -one (21) days of receipt of this Notice. If you fail to obtain a Release from this Notice or fail to request an administrative hearing within the twenty -one (21) day deadline you waive your right to a hearing and the Department may enter a Final Order imposing up to the maximum penalties as authorized by Florida Law. DACS -03419 Rev. 01/09 I have read this notice of rights: SIGNATURE OF OWNER DATE [] PURSUANT TO Section 616.242(7), F.S., AN INSPECTION CERTIFICATE IS ISSUED, when box is checked. The above identified amusement ride meets the requirements of Section 616.242, F.S. and Chapter 5F -8, F.A.C. and the deficien ies noted above (if any) have been corrected. INSPECTION CERTFICATE (DACS 03550, Rev. 01/09) # is' C C I acknowledge receipt of this inspection report and the NOTICE OF RIGHTS on the reverse side of this form. I certify this amusement ride is in compliance with §616.242, F.S. The employee responsible for operating this ride has been trained in accordance with §616.242(16), F.S. and the manufacturers operating instructions or the operating fact sheets for this ride are available to the operator, and the last 14 daily inspection reports were completed and available upon request. / ',t . Owner/Mana•er S ature Inssector's Si nature PURSUANT TO Section 616.242(7), F.S., the above identified amusement ride does not meet the requirements of Section 616.242, F.S. and Chapter 5F -8, F.A.C. and shall not operate until it passes a subsequent inspection by the Department. STOP OPERATION ORDER (DACS 03545, Rev. 01/09) # Owner /Mana• er Si nature Ins .ector's Si :nature DACS -03419 Rev. 12/09 White /Bureau Canary/ Owner or Manager Pink/Event Inspection - of , _ CHARLES H. BRONSON COMMISSIONER DATA: Date Inspector Event Location KIDDIE NON - KIDDIE 1. RIDE STATUS a.( ) Permit b.( ) Insurance c.( ) Compliance /NDT d.( ) Manuals 4. ATTACHMENTS a.( -) Gen Attachments b.(') Carrier/Tubs c.(') Restraints d.(,) Sweeps DEFICIENCIES: RESULTS: Florida Department of Agriculture and Consumer Services Bureau of Fair Rides Inspection AMUSEMENT RIDE INSPECTION REPORT Section 616.242(4), Florida Statutes Rule 5F- 8.0012, Florida Administrative Code Phone (850) 488 -9790; Fax (850) 488 -9023 Ride Owner Ride Name MFG Serial # USAID # Permit # SUPER REQUIREMENTS: (Check each requirement as it is accomplished or place (N) if not applicable) 2. INSTALLATION a.( ) Blocking b.(•') Fencing /Guarding c.( /1 Braces /Guys /Anchors d.(') Signs e.( Electrical 5. OPERATION a.( ) RPM Check b.(') Controls c.( 1 Brakes d.( ) Limit Controls Scheduled — Unannounced Re- inspection — Permit Inspection /Red Tag History Temporary — Permanent Location When Facing: L. R. 3. STRUCTURAL a.( ) Hydraulics /Pneumatics b.( ) Pins /Bolts /Keys c.( ) Structural Integrity d.( ) Tires/Wheels /Casters e.( 1 Bearings /Spindles /Axles f. (A) Track/Rim Iron 6. OTHER a.( ) Automatic Sprinkler /Smoke Detector b.( ) Water Quality c.( Bungy Cords d.(/-) Cranes e.(y) Comments Administrative Hearing Available If you wish to contest the Department's action, you have the right to request an administrative hearing to be conducted in accordance with Sections 120.569 and 120.57, Florida Statutes and to be represented by counsel or other qualified representative. Your request for hearing must contain: 1. Your name, address, and telephone number, and facsimile number (if any). 2. The name, address, and telephone number, and facsimile number of your attorney or qualified representative (if any) upon whom service of pleadings and other papers shall be made. 3. A statement that you are requesting an administrative hearing and dispute the material facts alleged by the department, in which case you must identify the material facts that are in dispute (formal hearing), or that you request an administrative hearing and that you do not dispute the facts alleged by the department (informal hearing). 4. A statement of when (date) you received this Notice and the file number of this Notice. Your request for a hearing must be received at the address shown on this Notice within twenty -one (21) days of receipt of this Notice. If you fail to obtain a Release from this Notice or fail to request an administrative hearing within the twenty -one (21) day deadline you waive your right to a hearing and the Department may enter a Final Order imposing up to the maximum penalties as authorized by Florida Law. DACS -03419 Rev. 01/09 have read this notice of rights: SIGNATURE OF OWNER DATE h El PURSUANT TO Section 616.242(7), F.S., AN INSPECTION CERTIFICATE IS ISSUED, when box is checked. The above identified amusement ride meets the requirements of Section 616.242, F.S. and Chapter 5F -8, F.A.C. and the deficiencies noted above (if any) have been corrected. INSPECTION CERTFICATE (DACS 03550, Rev. 01/09) # I acknowledge ride is §616.242(16), and the receipt of this inspection report and the NOTICE OF RIGHTS on the reverse side of this form. I certify this amusement in compliance with §616.242, F.S. The employee responsible for operating this ride has been trained in accordance with F.S. and the manufacturers operating instructions or the operating fact sheets for this ride are available to the operator, last 14 daily inspection .reports were completed and available upon request. "' s `�� Owher/Mana • er Si: nature Ins. ector's Si • nature PURSUANT TO Section 616.242(7), F.S., the above identified amusement ride does not meet the requirements of Section 616.242, F.S. and Chapter 5F -8, F.A.C. and shall not operate until it passes a subsequent inspection by the Department. STOP OPERATION ORDER (DACS 03545, Rev. 01/09) # Owner /Manager Signature Inspector's Signature CHARLES H. BRONSON COMMISSIONER DATA: Date G>f._ — // Inspector Event Location Ride Owner Ride Name MFG Serial # USAID # Permit # KIDDIE NON - KIDDIE SUPER REQUIREMENTS: (Check each requirement as it is accomplished or place (N) if not applicable) 1. RIDE STATUS a.( ) Permit b.( ) Insurance c.( ) Compliance /NDT d.( ) Manuals 4. ATTACHMENTS a.(- -j"Gen Attachments b.( - 1 Carrier/Tubs c.(- -) Restraints d.(..) Sweeps DEFICIENCIES: RESULTS: ,ry h J / ri 4 DACS -03419 Rev. 12/09 e/ r Florida Department of Agriculture and Consumer Services Bureau of Fair Rides Inspection AMUSEMENT RIDE INSPECTION REPORT Section 616.242(4), Florida Statutes Rule 5F- 8.0012, Florida Administrative Code Phone (850) 488 -9790; Fax (850) 488 -9023 r�- White /Bureau 2. INSTALLATION a.(. b.(-)' Fencing /Guarding c.( .1 Braces /Guys /Anchors d.( ')"Signs e.( lElectrical 5. OPERATION a.(,.)° RPM Check b.(4 Controls c.(i Brakes Limit Controls sr yud L r ac rya Canary/ Owner or Manager 3. STRUCTURAL a.( ) Hydraulics /Pneumatics b.( ) Pins /Bolts /Keys c.(1 Structural Integrity d.(4 Tires/Wheels /Casters e.(/) Bearings /Spindles /Axles f. Track/Rim Iron 6. OTHER a. ( -) Automatic Sprinkler /Smoke Detector b.( Water Quality c.(.) Bungy Cords d.( -) Cranes e.( ) Comments i z o Pink/Event Scheduled - Unannounced Re- inspection - Permit Inspection /Red Tag History Temporary- Permanent Location When Facing: L. R. Inspection - of DACS -03419 Rev. 01/09 Administrative Hearing Available If you wish to contest the Department's action, you have the right to request an administrative hearing to be conducted in accordance with Sections 120.569 and 120.57, Florida Statutes and to be represented by counsel or other qualified representative. Your request for hearing must contain: 1. Your name, address, and telephone number, and facsimile number (if any). 2. The name, address, and telephone number, and facsimile number of your attorney or qualified representative (if any) upon whom service of pleadings and other papers shall be made. 3. A statement that you are requesting an administrative hearing and dispute the material facts alleged by the department, in which case you must identify the material facts that are in dispute (formal hearing), or that you request an administrative hearing and that you do not dispute the facts alleged by the department (informal hearing). 4. A statement of when (date) you received this Notice and the file number of this Notice. Your request for a hearing must be received at the address shown on this Notice within twenty -one (21) days of receipt of this Notice. If you fail to obtain a Release from this Notice or fail to request an administrative hearing within the twenty -one (21) day deadline you waive your right to a hearing and the Department may enter a Final Order imposing up to the maximum penalties as authorized by Florida Law. I have read this notice of rights: SIGNATURE OF OWNER DATE CHARLES H. BRONSON COMMISSIONER DATA: Date Inspector Event Location e) /_ l7-- Ride Owner °" " Scheduled - Unannounced €" s -' t..e Ride Name Re- inspection - Permit MFG Inspection /Red Tag History Ale? e Serial # Temporary - Permanent USAID # Location When Facing: Permit # ; 8 2 3.- L. R. 4 i/4- L KIDDIE NON - KIDDIE SUPER REQUIREMENTS: (Check each requirement as it is accomplished or place (N) if not applicable) 1. RIDE STATUS a.(- °Permit b.(rf Insurance c.(- Compliance /N DT d.(4 Manuals 4. ATTACHMENTS a.(- '"Gen Attachments b.(4 Carrier/Tubs c.('f Restraints d.( .)'Sweeps DEFICIENCIES: AL ESULTS: DACS -03419 Rev. 12/09 Florida Department of Agriculture and Consumer Services Bureau of Fair Rides Inspection AMUSEMENT RIDE INSPECTION REPORT White /Bureau - �9..or-. Section 616.242(4), Florida Statutes Rule 5F- 8.0012, Florida Administrative Code Phone (850) 488 -9790; Fax (850) 488 -9023 2. INSTALLATION a.(_4-Blocking b.( - Fencing /Guarding c.( 4 Braces /Guys /Anchors d.(. Signs e.( )- Electrical 5. OPERATION a.( - 1 RPM Check b.(1 Controls c.(1 Brakes d.(4 Limit Controls Canary ! Owner or Manager 3. STRUCTURAL a.(4 Hydraulics /Pneumatics b.(-1" Pins /Bolts /Keys c. ("Structural Integrity d.(,,)- Tires/Wheels /Casters e.(,) Bearings /Spindles /Axles f. ( Track/Rim Iron 6. OTHER a.(4Automatic Sprinkler /Smoke Detector b.( 4 -Water Quality c.(--) Bungy Cords d.(1 Cranes e.( 1 Comments Inspection PURSUANT TO Section 616.242(7), F.S., AN INSPECTION CERTIFICATE IS ISSUED, when box is checked. The above identified amusement ride meets the requirements of Section 616.242, F.S. and Chapter 5F -8, F.A.C. and the deficiencies noted above (if any) have been corrected. INSPECTION CERTFICATE (DACS 03550, Rev. 01/09) # /Z 8 G.x'`7 I acknowledge ride is §616.242(16), and the receipt of this inspection report and the NOTICE OF RIGHTS on the reverse side of this form. I certify this amusement in compliance with §616.242, F.S. The employee responsible for operating this ride has been trained in accordance with F.S. anc manufacturers operating instructions or the operating fact sheets for this ride are available to the operator, last 14 daily insp tion repoits'°were completed and available upon request. wne anager Signature Inspector's Signature PURSUANT TO Section 616.242(7), F.S., the above identified amusement ride does not meet the requirements of Section 616.242, F.S. and Chapter 5F -8, F.A.C. and shall not operate until it passes a subsequent inspection by the Department. STOP OPERATION ORDER (DACS 03545, Rev. 01/09) # Owner/Manager Signature Inspector's Signature — CHARLES H. BRONSON COMMISSIONER DATA: Date Inspector Event Location e) /_ l7-- Ride Owner °" " Scheduled - Unannounced €" s -' t..e Ride Name Re- inspection - Permit MFG Inspection /Red Tag History Ale? e Serial # Temporary - Permanent USAID # Location When Facing: Permit # ; 8 2 3.- L. R. 4 i/4- L KIDDIE NON - KIDDIE SUPER REQUIREMENTS: (Check each requirement as it is accomplished or place (N) if not applicable) 1. RIDE STATUS a.(- °Permit b.(rf Insurance c.(- Compliance /N DT d.(4 Manuals 4. ATTACHMENTS a.(- '"Gen Attachments b.(4 Carrier/Tubs c.('f Restraints d.( .)'Sweeps DEFICIENCIES: AL ESULTS: DACS -03419 Rev. 12/09 Florida Department of Agriculture and Consumer Services Bureau of Fair Rides Inspection AMUSEMENT RIDE INSPECTION REPORT White /Bureau - �9..or-. Section 616.242(4), Florida Statutes Rule 5F- 8.0012, Florida Administrative Code Phone (850) 488 -9790; Fax (850) 488 -9023 2. INSTALLATION a.(_4-Blocking b.( - Fencing /Guarding c.( 4 Braces /Guys /Anchors d.(. Signs e.( )- Electrical 5. OPERATION a.( - 1 RPM Check b.(1 Controls c.(1 Brakes d.(4 Limit Controls Canary ! Owner or Manager 3. STRUCTURAL a.(4 Hydraulics /Pneumatics b.(-1" Pins /Bolts /Keys c. ("Structural Integrity d.(,,)- Tires/Wheels /Casters e.(,) Bearings /Spindles /Axles f. ( Track/Rim Iron 6. OTHER a.(4Automatic Sprinkler /Smoke Detector b.( 4 -Water Quality c.(--) Bungy Cords d.(1 Cranes e.( 1 Comments Inspection Administrative Hearing Available If you wish to contest the Department's action, you have the right to request an administrative hearing to be conducted in accordance with Sections 120.569 and 120.57, Florida Statutes and to be represented by counsel or other qualified representative. Your request for hearing must contain: 1. Your name, address, and telephone number, and facsimile number (if any). 2. The name, address, and telephone number, and facsimile number of your attorney or qualified representative (if any) upon whom service of pleadings and other papers shall be made. 3. A statement that you are requesting an administrative hearing and dispute the material facts alleged by the department, in which case you must identify the material facts that are in dispute (formal hearing), or that you request an administrative hearing and that you do not dispute the facts alleged by the department (informal hearing). 4. A statement of when (date) you received this Notice and the file number of this Notice. Your request for a hearing must be received at the address shown on this Notice within twenty -one (21) days of receipt of this Notice. If you fail to obtain a Release from this Notice or fail to request an administrative hearing within the twenty -one (21) day deadline you waive your right to a hearing and the Department may enter a Final Order imposing up to the maximum penalties as authorized by Florida Law. DACS -03419 Rev. 01/09 I have read this notice of rights: SIGNATURE OF OWNER DATE ® PURSUANT TO Section 616.242(7), F.S., AN INSPECTION CERTIFICATE IS ISSUED, when box is checked. The above identified amusement ride meets the requirements of Section 616.242, F.S. and Chapter 5F -8, F.A.C. and the deficiencies noted above (if any) have been corrected. INSPECTION CERTFICATE (DACS 03550, Rev. 01/09) # I acknowledge ride is §616.242(16), and the receipt of this inspection report and the NOTICE OF RIGHTS on the reverse side of this form. I certify this amusement in compliance with §616.242, F.S. The employee responsible for operating this ride has been trained in accordance with F.S. and a manufacturers operating instructions or the operating fact sheets for this ride are available to the operator, last 14 daily in $eec n reports were completed and available upon request. Owner /Manager Signature Inspector's Signature PURSUANT TO Section 616.242(7), F.S., the above identified amusement ride does not meet the requirements of Section 616.242, F.S. and Chapter 5F -8, F.A.C. and shall not operate until it passes a subsequent inspection by the Department. STOP OPERATION ORDER (DACS 03545, Rev. 01/09) # Owner/Manager Signature Inspector's Signature CHARLES H. BRONSON COMMISSIONER DATA: Date Inspector Event Location — // Ride Owner Scheduled – Unannounced Ride Name Re- inspection – Permit '° ✓ L- MFG Inspection /Red Tag History Serial # Temporary – Permanent USAID # Location When Facing: Permit # L. ' r ' -'" R. , e-t" f KIDDIE NON - KIDDIE REQUIREMENTS: (Check each requirement as it is accomplished or place (N) if not applicable) 1. RIDE STATUS a.( ) Permit b.( ) Insurance c.( ) Compliance /NDT d.( ) Manuals 4. ATTACHMENTS a.( ° ) Gen Attachments b.(1 Carrier/Tubs c.(') Restraints d.(�) Sweeps DEFICIENCIES: RESULTS: DACS -03419 Rev. 12/09 Florida Department of Agriculture and Consumer Services Bureau of Fair Rides Inspection AMUSEMENT RIDE INSPECTION REPORT White /Bureau SUPER Section 616.242(4), Florida Statutes Rule 5F- 8.0012, Florida Administrative Code Phone (850) 488 -9790; Fax (850) 488 -9023 2. INSTALLATION a.(Blocking b.( ..)eFencing /Guarding c.( 4`$races /Guys /Anchors d.( Signs e.( ) Electrical 5. OPERATION a.(4 RPM Check b.(,,•) Controls c.( 4 d.(,)' Limit Controls c Canary/ Owner or Manager 3. STRUCTURAL a.( ) Hydraulics /Pneumatics b.( ) Pins /Bolts /Keys c.( ) Structural Integrity d.( ) Tires/Wheels /Casters e.( ) Bearings /Spindles /Axles f. (° ) Track /Rim Iron 6. OTHER a.( ) Automatic Sprinkler /Smoke Detector b.( .) Water Quality c.(.) Bungy Cords d.( ) Cranes e.( ) Comments Pink/Event Inspection - of Administrative Hearing Available If you wish to contest the Department's action, you have the right to request an administrative hearing to be conducted in accordance with Sections 120.569 and 120.57, Florida Statutes and to be represented by counsel or other qualified representative. Your request for hearing must contain: 1. Your name, address, and telephone number, and facsimile number (if any). 2. The name, address, and telephone number, and facsimile number of your attorney or qualified representative (if any) upon whom service of pleadings and other papers shall be made. 3. A statement that you are requesting an administrative hearing and dispute the material facts alleged by the department, in which case you must identify the material facts that are in dispute (formal hearing), or that you request an administrative hearing and that you do not dispute the facts alleged by the department (informal hearing). 4. A statement of when (date) you received this Notice and the file number of this Notice. Your request for a hearing must be received at the address shown on this Notice within twenty -one (21) days of receipt of this Notice. If you fail to obtain a Release from this Notice or fail to request an administrative hearing within the twenty -one (21) day deadline you waive your right to a hearing and the Department may enter a Final Order imposing up to the maximum penalties as authorized by Florida Law. DACS -03419 Rev. 01/09 I have read this notice of rights: SIGNATURE OF OWNER DATE p PURSUANT TO Section 616.242(7), F.S., AN INSPECTION CERTIFICATE IS ISSUED, when box is checked. The above identified amusement ride meets the requirements of Section 616.242, F.S. and Chapter 5F -8, F.A.C. and the deficiencies noted above (if any) have been corrected. INSPECTION CERTFICATE (DACS 03550, Rev. 01/09) # I acknowledge ride is §616.242(16), and the receipt of this inspection report and the NOTICE OF RIGHTS on the reverse side of this form. I certify this amusement in compliance with §616.242, F.S. The employee responsible for operating this ride has been trained in accordance with F.S." and the man 1 Bail in ®ectti reports wo facturer re completed and available upon request. operating instructions or the operating fact sheets for this ride are available to the operator, last -/ ' Ow er/Manager Signa - Inspector's Signature PURSUANT TO Section 616.242(7), F.S., the above identified amusement ride does not meet the requirements of Section 616.242, F.S. and Chapter 5F -8, F.A.C. and shall not operate until it passes a subsequent inspection by the Department. STOP OPERATION ORDER (DACS 03545, Rev. 01/09) # Owner/Manager Signature Inspector's Signature r . . -_ I CHARLES H. BRONSON COMMISSIONER DATA: Date Inspector Event Location KIDDIE NON - KIDDIE SUPER REQUIREMENTS: (Check each requirement as it is accomplished 1. RIDE STATUS a.(- Permit b.(,) Insurance c.('j Compliance /NDT d.(1 Manuals 4. ATTACHMENTS a.( -) Gen Attachments b.(.4- Carrier/Tubs c.(-1 Restraints d. (.4'Sweeps DEFICIENCIES: DACS -03419 Rev. 12/09 Florida Department of Agriculture and Consumer Services Bureau of Fair Rides Inspection AMUSEMENT RIDE INSPECTION REPORT White /Bureau Section 616.242(4), Florida Statutes Rule 5F- 8.0012, Florida Administrative Code Phone (850) 488 -9790; Fax (850) 488 -9023 Ride Owner Ride Name MFG Serial # USAID # Permit # or p 2. INSTALLATION a.(4 Blocking b.(.- Fencing/Guarding c.(') Braces /Guys /Anchors d.(4 Signs e.(_.) Electrical 5. OPERATION a.(- RPM Check b.( 4 Controls c.(1 Brakes d.(4 Limit Controls anary / Owner or M anager r lace (N) if not applicable) 3. STRUCTURAL a.( 4- Hydraulics /Pneumatics b.( - "'Pins /Bolts /Keys c.(1 Integrity d. (Ay Tires/Wheels /Casters e.(1 Bearings /Spindles /Axles f. (,d.Track /Rim Iron 6. OTHER a.(4 Automatic Sprinkler /Smoke Detector b.(9 Water Quality c.(4 Bungy Cords d.O Cranes e.('y Comments Scheduled L Re- inspection - Permit Inspection /Red Tag History Temporary - Permanent Location When Facing: L. /' .. f R. ! ./ Inspection of If you wish to contest the Department's action, you have the right to request an administrative hearing to be conducted in accordance with Sections 120.569 and 120.57, Florida Statutes and to be represented by counsel or other qualified representative. Your request for hearing must contain: 1. Your name, address, and telephone number, and facsimile number (if any). 2. The name, address, and telephone number, and facsimile number of your attorney or qualified representative (if any) upon whom service of pleadings and other papers shall be made. 3. A statement that you are requesting an administrative hearing and dispute the material facts alleged by the department, in which case you must identify the material facts that are in dispute (formal hearing), or that you request an administrative hearing and that you do not dispute the facts alleged by the department (informal hearing). 4. A statement of when (date) you received this Notice and the file number of this Notice. Your request for a hearing must be received at the address shown on this Notice within twenty -one (21) days of receipt of this Notice. If you fail to obtain a Release from this Notice or fail to request an administrative hearing within the twenty -one (21) day deadline you waive your right to a hearing and the Department may enter a Final Order imposing up to the maximum penalties as authorized by Florida Law. DACS -03419 Rev. 01/09 Administrative Hearing Available I have read this notice of rights: SIGNATURE OF OWNER DATE CHARLES H. BRONSON COMMISSIONER DATA: Date Inspector Event Location Florida Department of Agriculture and Consumer Services Bureau of Fair Rides Inspection AMUSEMENT RIDE INSPECTION REPORT .rid Section 616.242(4), Florida Statutes Rule 5F- 8.0012, Florida Administrative Code Phone (850) 488 -9790; Fax (850) 488 -9023 Ride Owner Ride Name MFG Serial # USAID # Permit # 7 7a ' r� .4- i KIDDIE NON - KIDDIE SUPER REQUIREMENTS: (Check each requirement as it is accomplished or place (N) if not applicable) 1. RIDE STATUS a.( .) Permit b.( ) Insurance c.( ) Compliance /NDT d.( ) Manuals 4. ATTACHMENTS a.( ) Gen Attachments b.( )'Carrier/Tubs c.( - )"Restraints d.( ) Sweeps DEFICIENCIES: RESULTS: DACS -03419 Rev. 12/09 ' Lir c ^ .r m" ,/ "" White /Bureau 2. INSTALLATION a.( ) Blocking b.( ) Fencing /Guarding c.(. ) Braces /Guys /Anchors d.( ) Signs e.( ) Electrical 5. OPERATION a.( ) RPM Check b.( ) Controls c.( ) Brakes d.( ) Limit Controls • ../ f a ..� 64, Canary/ Owner or Manager r C J ° j l ' i 'Scheduled Unannounced Re- inspection — Permit Inspection /Red Tag History Temporary — Permanent Location When Facing; L. R. 3. STRUCTURAL a.(. ) Hydraulics /Pneumatics b.( ) Pins /Bolts /Keys c.(,, ) Structural Integrity d.(') Tires/Wheels /Casters e.(1) Bearings /Spindles /Axles f. Track/Rim Iron 6. OTHER a.(,Automatic Sprinkler /Smoke Detector b.(,43'Water Quality c.(�) Bungy Cords d.( ) Cranes e.( ) Comments j Pin vent v f ./.4--..er Inspection PURSUANT TO Section 616.242(7), F.S., AN INSPECTION CERTIFICATE IS ISSUED, when box is checked. The above identified amusement ride meets the requirements of Section 616.242, F.S. and Chapter 5F -8, F.A.C. and the deficiencies noted above (if any) have been corrected. INSPECTION CERTFICATE (DACS 03550, Rev. 01109) # I acknowledge ride is §616.242(16), and the receipt of this inspection report and the NOTICE OF RIGHTS on the reverse side of this form. I certify this amusement in compliance with §616.242, F.S. The employee responsible for operating this ride has been trained in accordance with F.S. and the manufacturers operating instructions or the operating fact sheets for this ride are available to the operator, last 14 daily inspection reports were completed and available upon request. /1) (?„0/2 (4) Owner/Manager Signature Inspector's Signature PURSUANT TO Section 616.242(7), F.S., the above identified amusement ride does not meet the requirements of Section 616.242, F.S. and Chapter 5F -8, F.A.C. and shall not operate until it passes a subsequent inspection by the Department. STOP OPERATION ORDER (DACS 03545, Rev. 01/09) # Owner/Manager Signature Inspector's Signature CHARLES H. BRONSON COMMISSIONER DATA: Date Inspector Event Location Florida Department of Agriculture and Consumer Services Bureau of Fair Rides Inspection AMUSEMENT RIDE INSPECTION REPORT .rid Section 616.242(4), Florida Statutes Rule 5F- 8.0012, Florida Administrative Code Phone (850) 488 -9790; Fax (850) 488 -9023 Ride Owner Ride Name MFG Serial # USAID # Permit # 7 7a ' r� .4- i KIDDIE NON - KIDDIE SUPER REQUIREMENTS: (Check each requirement as it is accomplished or place (N) if not applicable) 1. RIDE STATUS a.( .) Permit b.( ) Insurance c.( ) Compliance /NDT d.( ) Manuals 4. ATTACHMENTS a.( ) Gen Attachments b.( )'Carrier/Tubs c.( - )"Restraints d.( ) Sweeps DEFICIENCIES: RESULTS: DACS -03419 Rev. 12/09 ' Lir c ^ .r m" ,/ "" White /Bureau 2. INSTALLATION a.( ) Blocking b.( ) Fencing /Guarding c.(. ) Braces /Guys /Anchors d.( ) Signs e.( ) Electrical 5. OPERATION a.( ) RPM Check b.( ) Controls c.( ) Brakes d.( ) Limit Controls • ../ f a ..� 64, Canary/ Owner or Manager r C J ° j l ' i 'Scheduled Unannounced Re- inspection — Permit Inspection /Red Tag History Temporary — Permanent Location When Facing; L. R. 3. STRUCTURAL a.(. ) Hydraulics /Pneumatics b.( ) Pins /Bolts /Keys c.(,, ) Structural Integrity d.(') Tires/Wheels /Casters e.(1) Bearings /Spindles /Axles f. Track/Rim Iron 6. OTHER a.(,Automatic Sprinkler /Smoke Detector b.(,43'Water Quality c.(�) Bungy Cords d.( ) Cranes e.( ) Comments j Pin vent v f ./.4--..er Inspection If you wish to contest the Department's action, you have the right to request an administrative hearing to be conducted in accordance with Sections 120.569 and 120.57, Florida Statutes and to be represented by counsel or other qualified representative. Your request for hearing must contain: 1. Your name, address, and telephone number, and facsimile number (if any). 2. The name, address, and telephone number, and facsimile number of your attorney or qualified representative (if any) upon whom service of pleadings and other papers shall be made. 3. A statement that you are requesting an administrative hearing and dispute the material facts alleged by the department, in which case you must identify the material facts that are in dispute (formal hearing), or that you request an administrative hearing and that you do not dispute the facts alleged by the department (informal hearing). 4. A statement of when (date) you received this Notice and the file number of this Notice. Your request for a hearing must be received at the address shown on this Notice within twenty -one (21) days of receipt of this Notice. If you fail to obtain a Release from this Notice or fail to request an administrative hearing within the twenty -one (21) day deadline you waive your right to a hearing and the Department may enter a Final Order imposing up to the maximum penalties as authorized by Florida Law. DACS -03419 Rev. 01/09 Administrative Hearing Available I have read this notice of rights: SIGNATURE OF OWNER DATE CHARLES H. BRONSOW " COMMISSIONER DATA: Date Inspector "2 Event Location DEFICIENCIES: RESULTS: 1. RIDE STATUS a.( ) Permit b.( ) Insurance c.( ) Compliance /NDT d.( ) Manuals 4. ATTACHMENTS a.( ) Gen Attachments b.( ) Carrier/Tubs c.( ) Restraints d.( ) Sweeps DACS -03419 Rev.: h 2/09 7 Florida Department of Agriculture and Consumer Services Bureau of Fair Rides Inspection AMUSEMENT RIDE INSPECTION REPORT Ride Owner - L: ".... Ride Name MFG Serial # a White /Bureau Section 616.242(4), Florida Statutes Rule 5F- 8.0012, Florida Administrative Code Phone (850) 488 -9790; Fax (850) 488 -9023 2. INSTALLATION a.( ) Blocking b.( ) Fencing /Guarding c.( ) Braces /Guys /Anchors d.( ) Signs e.( ) Electrical 5. OPERATION a.( ) RPM Check b.( ) Controls c.( ) Brakes d.( ) Limit Controls Canary/ Owner or Manager USAID # Permit # KIDDIE NON - KIDDIE SUPER REQUIREMENTS: (Check each requirement as it is accomplished or place (N) if not applicable) In vent Scheduled - Unannounced Re- inspection – Permit Inspection /Red Tag History Temporary - Permanent Location When Facing: L. R. 3. STRUCTURAL a.( ) Hydraulics /Pneumatics b.( ) Pins /Bolts /Keys c.( ) Structural Integrity d.( ) Tires/Wheels /Casters e.( ) Bearings /Spindles /Axles f. ( ) Track /Rim Iron 6. OTHER a.( ) Automatic Sprinkler /Smoke Detector b.( ) Water Quality c.( ) Bungy Cords d.( ) Cranes e.( ) Comments Inspection of PURSUANT TO Section 616.242(7), F.S., AN INSPECTION CERTIFICATE IS ISSUED, when box is checked. The above identified amusement ride meets the requirements of Section 616.242, F.S. and Chapter 5F -8, F.A.C. and the deficiencies noted above (if any) have been corrected. INSPECTION CERTFICATE (DACS 03550, Rev. 01/09) # • 1 acknowledge ride is §616.242(16), and the receipt of this inspection report and the NOTICE OF RIGHTS on the reverse side of this form. I certify this amusement in compliance with §616.242, F.S. The employee responsible for operating this ride has been trained in accordance with F.S. and the manufacturers operating instructions or the operating fact sheets for this ride are available to the operator, last 14 daily inspection reports were completed and available upon request. Owner /Manager Signature Inspector's Signature PURSUANT TO Section 616.242(7), F.S., the above identified amusement ride does not meet the requirements of Section 616.242, F.S. and Chapter 5F -8, F.A.C. and shall not operate until it passes a subsequent inspection by the Department. STOP OPERATION ORD ERIDACS 03545, Rev. 01/09) # f!,I 2 d'wner/N an ager Signature 7 Inspector's Signature CHARLES H. BRONSOW " COMMISSIONER DATA: Date Inspector "2 Event Location DEFICIENCIES: RESULTS: 1. RIDE STATUS a.( ) Permit b.( ) Insurance c.( ) Compliance /NDT d.( ) Manuals 4. ATTACHMENTS a.( ) Gen Attachments b.( ) Carrier/Tubs c.( ) Restraints d.( ) Sweeps DACS -03419 Rev.: h 2/09 7 Florida Department of Agriculture and Consumer Services Bureau of Fair Rides Inspection AMUSEMENT RIDE INSPECTION REPORT Ride Owner - L: ".... Ride Name MFG Serial # a White /Bureau Section 616.242(4), Florida Statutes Rule 5F- 8.0012, Florida Administrative Code Phone (850) 488 -9790; Fax (850) 488 -9023 2. INSTALLATION a.( ) Blocking b.( ) Fencing /Guarding c.( ) Braces /Guys /Anchors d.( ) Signs e.( ) Electrical 5. OPERATION a.( ) RPM Check b.( ) Controls c.( ) Brakes d.( ) Limit Controls Canary/ Owner or Manager USAID # Permit # KIDDIE NON - KIDDIE SUPER REQUIREMENTS: (Check each requirement as it is accomplished or place (N) if not applicable) In vent Scheduled - Unannounced Re- inspection – Permit Inspection /Red Tag History Temporary - Permanent Location When Facing: L. R. 3. STRUCTURAL a.( ) Hydraulics /Pneumatics b.( ) Pins /Bolts /Keys c.( ) Structural Integrity d.( ) Tires/Wheels /Casters e.( ) Bearings /Spindles /Axles f. ( ) Track /Rim Iron 6. OTHER a.( ) Automatic Sprinkler /Smoke Detector b.( ) Water Quality c.( ) Bungy Cords d.( ) Cranes e.( ) Comments Inspection of If you wish to contest the Department's action, you have the right to request an administrative hearing to be conducted in accordance with Sections 120.569 and 120.57, Florida Statutes and to be represented by counsel or other qualified representative. Your request for hearing must contain: 1. Your name, address, and telephone number, and facsimile number (if any). 2. The name, address, and telephone number, and facsimile number of your attorney or qualified representative (if any) upon whom service of pleadings and other papers shall be made. 3. A statement that you are requesting an administrative hearing and dispute the material facts alleged by the department, in which case you must identify the material facts that are in dispute (formal hearing), or that you request an administrative hearing and that you do not dispute the facts alleged by the department (informal hearing). 4. A statement of when (date) you received this Notice and the file number of this Notice. Your request for a hearing must be received at the address shown on this Notice within twenty -one (21) days of receipt of this Notice. If you fail to obtain a Release from this Notice or fail to request an administrative hearing within the twenty -one (21) day deadline you waive your right to a hearing and the Department may enter a Final Order imposing up to the maximum penalties as authorized by Florida Law. DACS -03419 Rev. 01/09 Administrative Hearing Available I have read this notice of rights: SIGNATURE OF OWNER DATE ❑ PURSUANT TO Section 616.242(7), F.S., AN INSPECTION CERTIFICATE IS ISSUED, when box is checked. The above identified amusement ride meets the requirements of Section 616.242, F.S. and Chapter 5F -8, F.A.C. and the deficiencies noted above (if any) have been corrected. INSPECTION CERTFICATE (DACS 03550, Rev. 01/09) # I acknowledge ride is §616.242(16), and the receipt of this inspection report and the NOTICE OF RIGHTS on the reverse side of this form. I certify this amusement in compliance with §616.242, F.S. The employee responsible for operating this ride has been trained in accordance with F.S. and the manufacturers operating instructions or the operating fact sheets for this ride are available to the operator, last 14 daily inspe on reports were completed and available upon request. . . _./ Ow anger Sign Inspector's Signature PU UANT TO Section 616.242(7), F.S., the above identified amusement ride does not meet the requirements of Section 616.242, F.S. and Chapter 5F -8, F.A.C. and shall not operate until it passes a subsequent inspection by the Department. STOP OPERATION ORDER (DACS 03545, Rev. 01/09) # Owner /Manager Signature Inspector's Signature CHARLES H. BRONSON COMMISSIONER DATA: Date Inspector Event Location 7 KIDDIE NON - KIDDIE SUPER REQUIREMENTS: (Check each 1. RIDE STATUS a.( ) Permit b.( ) Insurance c.( ) Compliance /NDT d.( ) Manuals 4. ATTACHMENTS a.( ) Gen Attachments b.( ) Carrier/Tubs c.( ) Restraints d.( ) Sweeps DEFICIENCIES: RESULTS: DACS -03419 Rev. 12/09 Florida Department of Agriculture and Consumer Services Bureau of Fair Rides Inspection AMUSEMENT RIDE INSPECTION REPORT White /Bureau Section 616.242(4), Florida Statutes Rule 5F- 8.0012, Florida Administrative Code Phone (850) 488 -9790; Fax (850) 488 -9023 Ride Owner Ride Name MFG Serial # USAID # Permit # 5. OPERATION a.( ) RPM Check b.( ) Controls c.( ) Brakes d.( ) Limit Controls Canary/ Owner or Manager % c 6 L4 requirement as it is accomplished or place (N) if 2. INSTALLATION a.( ) Blocking b.( ) Fencing /Guarding c.( ) Braces /Guys /Anchors d.( ) Signs e.( ) Electrical inwtven Scheduled' Unannounced Re- inspection — Permit Inspection /Red Tag History Temporary — Permanent Location When Facing: L. R. not applicable) 3. STRUCTURAL a.( ) Hydraulics /Pneumatics b.( ) Pins /Bolts /Keys c.( ) Structural Integrity d.( ) Tires/Wheels /Casters e.( ) Bearings /Spindles /Axles f. ( ) Track/Rim Iron 6. OTHER a.( ) Automatic Sprinkler /Smoke Detector b.( ) Water Quality c.( ) Bungy Cords d.( ) Cranes e.( ) Comments Inspection If you wish to contest the Department's action, you have the right to request an administrative hearing to be conducted in accordance with Sections 120.569 and 120.57, Florida Statutes and to be represented by counsel or other qualified representative. Your request for hearing must contain: 1. Your name, address, and telephone number, and facsimile number (if any). 2. The name, address, and telephone number, and facsimile number of your attorney or qualified representative (if any) upon whom service of pleadings and other papers shall be made. 3. A statement that you are requesting an administrative hearing and dispute the material facts alleged by the department, in which case you must identify the material facts that are in dispute (formal hearing), or that you request an administrative hearing and that you do not dispute the facts alleged by the department (informal hearing). 4. A statement of when (date) you received this Notice and the file number of this Notice. Your request for a hearing must be received at the address shown on this Notice within twenty -one (21) days of receipt of this Notice. If you fail to obtain a Release from this Notice or fail to request an administrative hearing within the twenty -one (21) day deadline you waive your right to a hearing and the Department may enter a Final Order imposing up to the maximum penalties as authorized by Florida Law. DACS -03419 Rev. 01/09 Administrative Hearing Available I have read this notice of rights: SIGNATURE OF OWNER DATE p PURSUANT TO Section 616.242(7), F.S., AN INSPECTION CERTIFICATE IS ISSUED, when box is checked. The above identified amusement ride meets the requirements of Section 616.242, F.S. and Chapter 5F -8, F.A.C. and the deficiencies noted above (if any) have been corrected. INSPECTION CERTFICATE (DACS 03550, Rev. 01/09) # - 4, $ ' ' '=' I acknowledge ride is §616.242(16), and the receipt of this inspection report and the NOTICE OF RIGHTS on the reverse side of this form. I certify this amusement in compliance with §616.242, F.S. The employee responsible for operating this ride has been trained in accordance with F.S. and the manufacturers operating instructions or the operating fact sheets for th' ride are available to the operator, last 14 daily inspectii n,reports were completed and available upon request. Owner/Mer Signature Inspector's Signature PURSUANT TO Secti3 i"616.242(7), F.S., the above identified amusement ride does not meet the requirements of Section 616.242, F.S. and Chapter 5F -8, F.A.C. and shall not operate until it passes a subsequent inspection by the Department. STOP OPERATION ORDER (DACS 03545, Rev. 01/09) # Owner/Manager Signature Inspector's Signature CHARLES H. BRONSON COMMISSIONER DATA: Date Inspector Event Location KIDDIE NON - KIDDIE SUPER REQUIREMENTS: (Check each requirement as it is accomplished or place (N) if not applicable) 1. RIDE STATUS a.(Permit b.(...4 Insurance c.(-fi Compliance /NDT d.( -'f Manuals 4. ATTACHMENTS a.( ) Gen Attachments b.(`') Carrier/Tubs c.( ) Restraints d.( ) Sweeps DEFICIENCIES: RESULTS: DACS -03419 Rev. 12/09 r?YG1 7 7 , " / .-e 44- Florida Department of Agriculture and Consumer Services Bureau of Fair Rides Inspection AMUSEMENT RIDE INSPECTION REPORT White /Bureau Ride Name MFG Serial # USAID # Permit # 2. INSTALLATION a,(•'f Blocking b.( 1 Fencing /Guarding c.( - '"Braces /Guys /Anchors d.(AiSigns e.(d'Electrical 5. OPERATION a.( ) RPM Check b.( ) Controls c.( ) Brakes d.( ) Limit Controls Section 616.242(4), Florida Statutes Rule 5F- 8.0012, Florida Administrative Code Phone (850) 488 -9790; Fax (850) 488 -9023 Ride Owner ) ." i ' , cF 4 //r, 3o +.t Canary/ Owner or Manager 3. STRUCTURAL a.( Hydraulics /Pneumatics b. Pins /Bolts /Keys c.( Structural Integrity d.(`f Tires/Wheels /Casters e.(1'Bearings /Spindles /Axles f. (-1 Track /Rim Iron 6. OTHER a.( ) Automatic Sprinkler /Smoke Detector b.(;) Water Quality c.( ) Bungy Cords d.( ) Cranes e.( ) Comments inwtven Scheduled - Unannounced Re- inspection - Permit Inspection /Red Tag History Temporary - Permanent Location When Facing: L. R. Inspection fir DACS -03419 Rev. 01/09 Administrative Hearing Available If you wish to contest the Department's action, you have the right to request an administrative hearing to be conducted in accordance with Sections 120.569 and 120.57, Florida Statutes and to be represented by counsel or other qualified representative. Your request for hearing must contain: 1. Your name, address, and telephone number, and facsimile number (if any). 2. The name, address, and telephone number, and facsimile number of your attorney or qualified representative (if any) upon whom service of pleadings and other papers shall be made. 3. A statement that you are requesting an administrative hearing and dispute the material facts alleged by the department, in which case you must identify the material facts that are in dispute (formal hearing), or that you request an administrative hearing and that you do not dispute the facts alleged by the department (informal hearing). 4. A statement of when (date) you received this Notice and the file number of this Notice. Your request for a hearing must be received at the address shown on this Notice within twenty -one (21) days of receipt of this Notice. If you fail to obtain a Release from this Notice or fail to request an administrative hearing within the twenty -one (21) day deadline you waive your right to a hearing and the Department may enter a Final Order imposing up to the maximum penalties as authorized by Florida Law. I have read this notice of rights: SIGNATURE OF OWNER DATE ri PURSUANT TO Section 616.242(7), F.S., AN INSPECTION CERTIFICATE IS ISSUED, when box is checked. The above identified amusement ride meets the requirements of Section 616.242, F.S. and Chapter 5F -8, F.A.C. and the deficiet cies noted above (if any) have been corrected. INSPECTION CERTFICATE (DACS 03550, Rev. 01/09)# / '- , --"I'':- , ' I acknowledge ride is §616.242(16), and the receipt of this inspection report and the NOTICE OF RIGHTS on the reverse side of this form. I certify this amusement in compliance with §616.242, F.S. The employee responsible for operating this ride has been trained in accordance with F.S. and the manufacturers operating instructions or the operating fact sheets for this ride are available to the operator, last 14 daily inspection reports were completed and available upon request. f Owner /Manager Signature - ^5,. r* Inspector's Signature PURSUANT TO Section 616.242(7), F.S., the above identified amusement ride does not meet the requirements of Section 616.242, F.S. and Chapter 5F -8, F.A.C. and shall not operate until it passes a subsequent inspection by the Department. STOP OPERATION ORDER (DACS 03545, Rev. 01/09) # Owner /Manager Signature Inspector's Signature CHARLES H. BRONSON COMMISSIONER DATA: Date Inspector Event Location 1 ../i,74-r Serial # n et — E 7-5.6 USAID# G73Z - Permit # 3 ,5,,,'` KIDDIE NON - KIDDIE SUPER REQUIREMENTS: (Check each requirement as it is accomplished or place (N) if not applicable) 1. RIDE STATUS a.( 4 Permit b.(,) Insurance c.() Compliance /NDT d.(.) Manuals 4. ATTACHMENTS a.(4'Gen Attachments b.() Carrier/Tubs c.( 4 Restraints d.( ) Sweeps DEFICIENCIES: �!7 ' -'v, n/ /2 .0 .4 • G 4. C.." 01 e ke Y : . Cw +�s ..,-J.1 / � . . . . ' r '904. r �. 1 / e c°, sH../w e. r e., • Cc.? ' ) .e 4 " , ( 7 0 J► -1- I CC / C.4.4.0.C.4.4.0C.4.4.0.91 + ■ C 44 r G 4._ 6 (' / RESULTS: DACS -03419 Rev. 12/09 0 •cl Florida Department of Agriculture and Consumer Services Bureau of Fair Rides Inspection AMUSEMENT RIDE INSPECTION REPORT White /Bureau Section 616.242(4), Florida Statutes Rule 5F- 8.0012, Florida Administrative Code Phone (850) 488 -9790; Fax (850) 488 -9023 Ride Owner Ride Name MFG 2. INSTALLATION a.( ) Blocking b.(1 Fencing /Guarding C.( 4'Braces /Guys /Anchors d.( Signs e.( Electrical 5. OPERATION a.(, RPM Check b.( ,)Controls c.( ) Brakes d.( ) Limit Controls i/e4 w1 5/.` �10 ve. 7�4 -7 /7 /,',i . :ass f774 ogle /��raivj J Canary/ Owner or Manager 3. STRUCTURAL a.( ) Hydraulics /Pneumatics b.( ) Pins /Bolts /Keys c.( ) Structural Integrity d.( .4-'Tires/Wheels /Casters e.( Bearings /Spindles /Axles f. ( Track/Rim Iron 6. OTHER a.( Sprinkler /Smoke Detector b.(&) Water Quality c.') Bungy Cords d.( ) Cranes e.( ) Comments 7;1-, / 71 1 1 - t (C) T g- , ., /7 f3 e �"P �/ .f i /✓ / Scheduled — Unannounced Re- inspection — Permit Inspection /Red Tag History Temporary — Permanent Location When Facing: L. /' , R. [..r,l - K 5 l� Pink/Event Inspection _ Of DACS -03419 Rev. 01/09 Administrative Hearing Available If you wish to contest the Department's action, you have the right to request an administrative hearing to be conducted in accordance with Sections 120.569 and 120.57, Florida Statutes and to be represented by counsel or other qualified representative. Your request for hearing must contain: 1. Your name, address, and telephone number, and facsimile number (if any). 2. The name, address, and telephone number, and facsimile number of your attorney or qualified representative (if any) upon whom service of pleadings and other papers shall be made. 3. A statement that you are requesting an administrative hearing and dispute the material facts alleged by the department, in which case you must identify the material facts that are in dispute (formal hearing), or that you request an administrative hearing and that you do not dispute the facts alleged by the department (informal hearing). 4. A statement of when (date) you received this Notice and the file number of this Notice. Your request for a hearing must be received at the address shown on this Notice within twenty -one (21) days of receipt of this Notice. If you fail to obtain a Release from this Notice or fail to request an administrative hearing within the twenty -one (21) day deadline you waive your right to a hearing and the Department may enter a Final Order imposing up to the maximum penalties as authorized by Florida Law. I have read this notice of rights: \ SIGNATURE OF OWNER DATE j PURSUANT TO Section 616.242(7), F.S., AN INSPECTION CERTIFICATE IS ISSUED, when box is checked. The above identified amusement ride meets the requirements of Section 616.242, F.S. and Chapter 5F -8, F.A.C. and the deficiencies noted above (if any) have been corrected. INSPECTION CERTFICATE (DACS 03550, Rev. 01/09) # I acknowledge ride is §616.242(16), and the receipt of this inspection report and the NOTICE OF RIGHTS on the reverse side of this form. I certify this amusement in compliance with §616.242, F.S. The employee responsible for operating this ride has been trained in accordance with F.S. and the manufacturers operating instructions or the operating fact sheets for this ride are available to the operator, last 14 daily inspectiop'feporttt• completed and available upon request. ✓f Owner/Manag ignature Inspector's Signature PURSUANT TO Section 616.242(7), F.S., the above identified amusement ride does not meet the requirements of Section 616.242, F.S. and Chapter 5F -8, F.A.C. and shall not operate until it passes a subsequent inspection by the Department. STOP OPERATION ORDER (DACS 03545, Rev. 01/09) # Owner/Manager Signature Inspector's Signature CHARLES H. BRONSON COMMISSIONER DATA: Date Inspector Event Location RESULTS: KIDDIE NON - KIDDIE REQUIREMENTS: (Check each 1. RIDE STATUS a.( ) Permit b.( ) Insurance c.( ) Compliance /NDT d.( ) Manuals 4. ATTACHMENTS a.( ) Gen Attachments b.( ) Carrier/Tubs c.( ) Restraints d.( ) Sweeps DEFICIENCIES: DACS -03419 Rev. 12/09 ,1... 7 Florida Department of Agriculture and Consumer Services Bureau of Fair Rides Inspection AMUSEMENT RIDE INSPECTION REPORT White /Bureau Section 616.242(4), Florida Statutes Rule 5F- 8.0012, Florida Administrative Code Phone (850) 488 -9790; Fax (850) 488 -9023 Ride Owner '''' ` " " "' ° Scheduled — Unannounced Ride Name � Re- inspection — Permit MFG Inspection /Red Tag History Serial # Temporary — Permanent USAID # Location When Facing: Permit # L. R. SUPER requirement as it is accomplished or place (N) if not applicable) 2. INSTALLATION a.( ) Blocking b.( ) Fencing /Guarding c.( ) Braces /Guys /Anchors d.( ) Signs e.( ) Electrical 5. OPERATION a.( ) RPM Check b.( ) Controls c.( ) Brakes d.( ) Limit Controls Canary/ Owner or Manager 3. STRUCTURAL a.( ) Hydraulics /Pneumatics b.( ) Pins /Bolts /Keys c.( ) Structural Integrity d.( ) Tires/Wheels /Casters e.( ) Bearings /Spindles /Axles f. ( ) Track/Rim Iron 6. OTHER a.( ) Automatic Sprinkler /Smoke Detector b.( ) Water Quality c.( ) Bungy Cords d.( ) Cranes e.( ) Comments Pink/Event Inspection DACS -03419 Rev. 01/09 Administrative Hearing Available If you wish to contest the Department's action, you have the right to request an administrative hearing to be conducted in accordance with Sections 120.569 and 120.57, Florida Statutes and to be represented by counsel or other qualified representative. Your request for hearing must contain: 1. Your name, address, and telephone number, and facsimile number (if any). 2. The name, address, and telephone number, and facsimile number of your attorney or qualified representative (if any) upon whom service of pleadings and other papers shall be made. 3. A statement that you are requesting an administrative hearing and dispute the material facts alleged by the department, in which case you must identify the material facts that are in dispute (formal hearing), or that you request an administrative hearing and that you do not dispute the facts alleged by the department (informal hearing). 4. A statement of when (date) you received this Notice and the file number of this Notice. Your request for a hearing must be received at the address shown on this Notice within twenty -one (21) days of receipt of this Notice. If you fail to obtain a Release from this Notice or fail to request an administrative hearing within the twenty -one (21) day deadline you waive your right to a hearing and the Department may enter a Final Order imposing up to the maximum penalties as authorized by Florida Law. I have read this notice of rights: SIGNATURE OF OWNER DATE ❑ PURSUANT TO Section 616.242(7), F.S., AN INSPECTION CERTIFICATE IS ISSUED, when box is checked. The above identified amusement ride meets the requirements of Section 616.242, F.S. and Chapter 5F -8, F.A.C. and the deficiencies noted above (if any) have been corrected. INSPECTION CERTFICATE (DACS 03550, Rev. 01/09) # I acknowledge ride is §616.242(16), and the receipt of this inspection report and the NOTICE OF RIGHTS on the reverse side of this form. I certify this amusement in compliance with §616.242, F.S. The employee responsible for operating this ride has been trained in accordance with F.S. and the manufacturers operating instructions or the operating fact sheets for this ride are available to the operator, last 14 daily ins ction reports were completed and available upon request. Owner/Manager Signature Inspector's Signature PURSUANT TO Section 616.242(7), F.S., the above identified amusement ride does not meet the requirements of Section 616.242, F.S. and Chapter 5F -8, F.A.C. and shall not operate until it passes a subsequent inspection by the Department. STOP OPERATION ORDER (DACS 03545, Rev. 01/09) # Owner/Manager Signature Inspector's Signature ^ r - -- .r t_ CHARLES H. BRONSON COMMISSIONER DATA: Date Inspector Event Location Ride Owner Ride Name MFG Serial # USAID # Permit # KIDDIE NON - KIDDIE SUPER REQUIREMENTS: (Check each requirement as it is accomplished or place (N) if not applicable) 1. RIDE STATUS a.( ) Permit b.( ) Insurance c.( ) Compliance /NDT d.( ) Manuals 4. ATTACHMENTS a.( ) Gen Attachments b.( ) Carrier/Tubs c.( ) Restraints d.( ) Sweeps DEFICIENCIES: DACS -03419 Rev. 12/09 Florida Department of Agriculture and Consumer Services Bureau of Fair Rides Inspection AMUSEMENT RIDE INSPECTION REPORT White /Bureau Section 616.242(4), Florida Statutes Rule 5F- 8.0012, Florida Administrative Code Phone (850) 488 -9790; Fax (850) 488 -9023 2. INSTALLATION a.( ) Blocking b.( ) Fencing /Guarding c.( ) Braces /Guys /Anchors d.( ) Signs e.( ) Electrical 5. OPERATION a.( ) RPM Check b.( ) Controls c.( ) Brakes d.( ) Limit Controls anary / Owner or Manager Scheduled — Unannounced Re- inspection — Permit Inspection /Red Tag History Temporary — Permanent Location When Facing: L. R. 3. STRUCTURAL a.( ) Hydraulics /Pneumatics b.( ) Pins /Bolts /Keys c.( ) Structural Integrity d.( ) Tires/Wheels /Casters e.( ) Bearings /Spindles /Axles f. ( ) Track /Rim Iron 6. OTHER a.( ) Automatic Sprinkler /Smoke Detector b.( ) Water Quality c.( ) Bungy Cords d.( ) Cranes e.( ) Comments Inspection Administrative Hearing Available If you wish to contest the Department's action, you have the right to request an administrative hearing to be conducted in accordance with Sections 120.569 and 120.57, Florida.Statutes and to be represented by counsel or other qualified representative. Your request for hearing must contain: 1. Your name, address, and telephone number, and facsimile number (if any). 2. The name, address, and telephone number, and facsimile number of your attorney or qualified representative (if any) upon whom service of pleadings and other papers shall be made. 3. A statement that you are requesting an administrative hearing and dispute the material facts alleged by the department, in which case you must identify the material facts that are in dispute (formal hearing), or that you request an administrative hearing and that you do not dispute the facts alleged by the department (informal hearing). 4. A statement of when (date) you received this Notice and the file number of this Notice. Your request for a hearing must be received at the address shown on this Notice within twenty -one (21) days of receipt of this Notice. If you fail to obtain a Release from this Notice or fail to request an administrative hearing within the twenty -one (21) day deadline you waive your right to a hearing and the Department may enter a Final Order imposing up to the maximum penalties as authorized by Florida Law. DACS -03419 Rev. 01/09 I have read this notice of rights: SIGNATURE OF OWNER DATE ❑ PURSUANT TO Section 616.242(7), F.S., AN INSPECTION CERTIFICATE IS ISSUED, when box is checked. The above identified amusement ride meets the requirements of Section 616.242, F.S. and Chapter 5F -8, F.A.C. and the deficiencies noted above (if any) have been corrected. INSPECTION CERTFICATE (DACS 03550, Rev. 01/09) # I acknowledge ride is §616.242(16), and the receipt of this inspection report and the NOTICE OF RIGHTS on the reverse side of this form. I certify this amusement in compliance with §616.242, F.S. The employee responsible for operating this ride has been trained in accordance with F.S. and the manufacturers operating instructions or the operating fact sheets for this ride are available to the operator, last 14 daily inspecti reports were completed and available upon request. / , / ' rJ Owner tanager Signature Inspector's Signature PURSUANT TO Section 616.24 , F.S., the above identified amusement ride does not meet the requirements of Section 616.242, F.S. and Chapter 5F -8, F.A.C. and shall not operate until it passes a subsequent inspection by the Department. STOP OPERATION ORDER (DACS 03545, Rev. 01/09) # Owner/Manager Signature Inspector's Signature CHARLES H. BRONSON COMMISSIONER DATA: Date Inspector Event Location KIDDIE NON - KIDDIE SUPER REQUIREMENTS: (Check each requirement as it is accomplished or place (N) if not applicable) 1. RIDE STATUS a.( ) Permit b.( ) Insurance c.( ) Compliance /NDT d.( ) Manuals 4. ATTACHMENTS a.( ) Gen Attachments b.( ) Carrier/Tubs c.( ) Restraints d.( ) Sweeps DEFICIENCIES: RESULTS: DACS -03419 Rev. 12/09 Florida Department of Agriculture and Consumer Services Bureau of Fair Rides Inspection AMUSEMENT RIDE INSPECTION REPORT White /Bureau Section 616.242(4), Florida Statutes Rule 5F- 8.0012, Florida Administrative Code Phone (850) 488 -9790; Fax (850) 488 -9023 Ride Owner Ride Name MFG Serial # USAID # Permit # 2. INSTALLATION a.( ) Blocking b.( ) Fencing /Guarding c.( ) Braces /Guys /Anchors d.( ) Signs e.( ) Electrical 5. OPERATION a.( ) RPM Check b.( ) Controls c.( ) Brakes d.( ) Limit Controls Canary/ Owner or Manager i./ %# •,$) G� 1 ' /. .. 'er t" f' •J Scheduled— Unannounced Re- inspection — Permit Inspection /Red Tag History Temporary — Permanent Location When Facing: L. R. 3. STRUCTURAL a.( ) Hydraulics /Pneumatics b.( ) Pins /Bolts /Keys c.( ) Structural Integrity d.( ) Tires/Wheels /Casters e.( ) Bearings /Spindles /Axles f. ( ) Track/Rim Iron 6. OTHER a.( ) Automatic Sprinkler /Smoke Detector b.( ) Water Quality c.( ) Bungy Cords d.( ) Cranes e.( ) Comments Pink/Event Inspection If you wish to contest the Department's action, you have the right to request an administrative hearing to be conducted in accordance with Sections 120.569 and 120.57, Florida Statutes and to be represented by counsel or other qualified representative. Your request for hearing must contain: 1. Your name, address, and telephone number, and facsimile number (if any). 2. The name, address, and telephone number, and facsimile number of your attorney or qualified representative (if any) upon whom service of pleadings and other papers shall be made. 3. A statement that you are requesting an administrative hearing and dispute the material facts alleged by the department, in which case you must identify the material facts that are in dispute (formal hearing), or that you request an administrative hearing and that you do not dispute the facts alleged by the department (informal hearing). 4. A statement of when (date) you received this Notice and the file number of this Notice. Your request for a hearing must be received at the address shown on this Notice within twenty -one (21) days of receipt of this Notice. If you fail to obtain a Release from this Notice or fail to request an administrative hearing within the twenty -one (21) day deadline you waive your right to a hearing and the Department may enter a Final Order imposing up to the maximum penalties as authorized by Florida Law. DACS -03419 Rev. 01/09 Administrative Hearing Available I have read this notice of rights: SIGNATURE OF OWNER DATE El PURSUANT TO Section 616.242(7), F.S., AN INSPECTION CERTIFICATE IS ISSUED, when box is checked. The above identified amusement ride meets the requirements of Section 616.242, F.S. and Chapter 5F -8, F.A.C. and the deficiencies noted above (if any) have been corrected. INSPECTION CERTFICATE (DACS 03550, Rev. 01/09) # / fC ` I acknowledge ride is §616.242(16), and the receipt of this inspection report and the NOTICE OF RIGHTS on the reverse side of this form. I certify this amusement in compliance with §616.242, F.S. The employee responsible for operating this ride has been trained in accordance with F.S. and'tfie manufacturers operating instructions or the operating fact sheets for this ride are available to the operator, last 14 daily inspection reports were completed and available upon request. i...1) R wn anager Signature Inspector's Signature PU UANT TO Section 616.242(7), F.S., the above identified amusement ride does not meet the requirements of Section 616.242, F.S. and Chapter 5F -8, F.A.C. and shall not operate until it passes a subsequent inspection by the Department. STOP OPERATION ORDER (DACS 03545, Rev. 01/09) # Owner/Manager Signature Inspector's Signature CHARLES H. BRONSON COMMISSIONER DATA: Date Ci Inspector r Event Location / - i KIDDIE NON - KIDDIE 1. RIDE STATUS a.(/j'Permit b.(') Insurance c.(.Compliance /NDT d.( Manuals 4. ATTACHMENTS a.(4 Gen Attachments b.(A Carrier/Tubs c.(' Restraints d.(4 Sweeps DEFICIENCIES: RESULTS: 4s/s! to wG DACS -03419 Rev. 12/09 4,1 Florida Department of Agriculture and Consumer Services Bureau of Fair Rides Inspection AMUSEMENT RIDE INSPECTION REPORT E_ White /Bureau SUPER Section 616.242(4), Florida Statutes Rule 5F- 8.0012, Florida Administrative Code Phone (850) 488 -9790; Fax (850) 488 -9023 Ride Owner Ride Name MFG Serial # USAID # Permit # REQUIREMENTS: (Check each requirement as it is accomplished or place (N) if not applicable) 5. OPERATION a.( ) RPM Check b.( ) Controls c.( ) Brakes d.( ) Limit Controls 2. INSTALLATION a.(4Blocking b.(4 Fencing /Guarding c.('j Braces /Guys /Anchors d.( ) Signs e.( ) Electrical G r ,J,•ot /C r y Ca /.,,r., f %7.-4 7 C)f / Yo.� Canary/ Owner or Manager L. 3. STRUCTURAL a.( ) Hydraulics /Pneumatics b.( ) Pins /Bolts /Keys c.( ) Structural Integrity d.( ) Tires/Wheels /Casters e.( ) Bearings /Spindles /Axles f. ( ) Track/Rim Iron 6. OTHER a.(A..) Automatic Sprinkler /Smoke Detector b.(1..) Water Quality c.(" ) Bungy Cords d.(') Cranes e.(/) Comments ''TZ z71 e e iniutven Scheduled ,00""' announced Re- inspection — Permit Inspection /Red Tag History Temporary — Permanent Location When Facing: 1 R. ( 7 Inspection - of DACS -03419 Rev. 01/09 Administrative Hearing Available If you wish to contest the Department's action, you have the right to request an administrative hearing to be conducted in accordance with Sections 120.569 and 120.57, Florida Statutes and to be represented by counsel or other qualified representative. Your request for hearing must contain: 1. Your name, address, and telephone number, and facsimile number (if any). 2. The name, address, and telephone number, and facsimile number of your attorney or qualified representative (if any) upon whom service of pleadings and other papers shall be made. 3. A statement that you are requesting an administrative hearing and dispute the material facts alleged by the department, in which case you must identify the material facts that are in dispute (formal hearing), or that you request an administrative hearing and that you do not dispute the facts alleged by the department (informal hearing). 4. A statement of when (date) you received this Notice and the file number of this Notice. Your request for a hearing must be received at the address shown on this Notice within twenty -one (21) days of receipt of this Notice. If you fail to obtain a Release from this Notice or fail to request an administrative hearing within the twenty -one (21) day deadline you waive your right to a hearing and the Department may enter a Final Order imposing up to the maximum penalties as authorized by Florida Law. I have read this notice of rights: SIGNATURE OF OWNER DATE F PURSUANT TO Section 616.242(7), F.S., AN INSPECTION CERTIFICATE IS ISSUED, when box is checked. The above identified amusement ride meets the requirements of Section 616.242, F.S. and Chapter 5F -8, F.A.C. and the deficiencies noted above (if any) have been corrected. INSPECTION CERTFICATE (DACS 03550, Rev. 01/09) # I acknowledge ride is §616.242(16), and the receipt of this inspection report and the NOTICE OF RIGHTS on the reverse side of this form. I certify this amusement in compliance.with §616.242, F.S. The employee responsible for operating this ride has been trained in accordance with F.S. and e manufacturers operating instructions or the operating fact sheets for this ride are available to the operator, last 14 ily i p tion reports were completed and available upon request. ,. O w r/Manager Signature Inspector's Signature PURSUANT TO Section 616.242(7), F.S., the above identified amusement ride does not meet the requirements of Section 616.242, F.S. and Chapter 5F -8, F.A.C. and shall not operate until it passes a subsequent inspection by the Department. STOP OPERATION ORDER (DACS 03545, Rev. 01/09) # Owner/Manager Signature Inspector's Signature CHARLES H. BRONSON COMMISSIONER DATA: Date Inspector Event Location RESULTS: / r KIDDIE NON - KIDDIE SUPER REQUIREMENTS: (Check each 1. RIDE STATUS a.(4 Permit b.(4 Insurance c.(4Compliance /NDT d.(1 Manuals 4. ATTACHMENTS a.(-) Gen Attachments b.(/) Carrier/Tubs c.('f Restraints d.(,3 Sweeps DEFICIENCIES: DACS -03419 Rev. 12/09 Florida Department of Agriculture and Consumer Services Bureau of Fair Rides Inspection AMUSEMENT RIDE INSPECTION REPORT White /Bureau Section 616.242(4), Florida Statutes Rule 5F- 8.0012, Florida Administrative Code Phone (850) 488 -9790; Fax (850) 488 -9023 Ride Owner Ride Name MFG Serial # USAID # Permit # h - :' 1k Z., r ; requirement as it is accomplished or place (N) if 2. INSTALLATION a.( ) Blocking b.(`) Fencing /Guarding c.O Braces /Guys /Anchors d.( ) Signs e.( ) Electrical 5. OPERATION a.(IRPM Check b.(,,) Controls c.(-1 Brakes d.(/) Limit Controls Canary/ Owner or Manager V 0 4Vs Pink/Event Scheduled — Unannounced Re- inspection — Permit Inspection /Red Tag History Temporary — Permanent Location When Facing: L. R. not applicable) 3. STRUCTURAL a.(.4 Hydraulics /Pneumatics b.(4 Pins /Bolts /Keys c. (4 Structural Integrity d.(1) Tires/Wheels /Casters e.('1 Bearings /Spindles /Axles f. (!`j°'Track/Rim Iron 6. OTHER a.( Sprinkler /Smoke Detector b.(v'Water Quality c.cer3ungy Cords d.(/'j Cranes e.(pComments Inspection t of ! If you wish to contest the Department's action, you have the right to request an administrative hearing to be conducted in accordance with Sections 120.569 and 120.57, Florida Statutes and to be represented by counsel or other qualified representative. Your request for hearing must contain: 1. Your name, address, and telephone number, and facsimile number (if any). 2. The name, address, and telephone number, and facsimile number of your attorney or qualified representative (if any) upon whom service of pleadings and other papers shall be made. 3. A statement that you are requesting an administrative hearing and dispute the material facts alleged by the department, in which case you must identify the material facts that are in dispute (formal hearing), or that you request an administrative hearing and that you do not dispute the facts alleged by the department (informal hearing). 4. A statement of when (date) you received this Notice and the file number of this Notice. Your request for a hearing must be received at the address shown on this Notice within twenty -one (21) days of receipt of this Notice. If you fail to obtain a Release from this Notice or fail to request an administrative hearing within the twenty -one (21) day deadline you waive your right to a hearing and the Department may enter a Final Order imposing up to the maximum penalties as authorized by Florida Law. DACS -03419 Rev. 01/09 Administrative Hearing Available I have read this notice of rights: SIGNATURE OF OWNER DATE ❑ PURSUANT TO Section 616.242(7), F.S., AN INSPECTION CERTIFICATE IS ISSUED, when box is checked. The above identified amusement ride meets the requirements of Section 616.242, F.S. and Chapter 5F -8, F.A.C. and the deficiencies noted above (if any) have been corrected. INSPECTION CERTFICATE (DACS 03550, Rev. 01/09) # I acknowledge ride is §616.242(16), and the receipt of this inspection report and the NOTICE OF RIGHTS on the reverse side of this form. I certify this amusement in compliance with §616.242, F.S. The employee responsible for operating this ride has been trained in accordance with F.S. and the manufacturers operating instructions or the operating fact sheets for this ride are available to the operator, last 14 daily inspection reports were completed and available upon request. / f ` Own anager Signature - .",,,.yam-,. Inspector's Signature PURSUANT TO Section 616.242(7), F.S., the above identified amusement ride does not meet the requirements of Section 616.242, F.S. and Chapter 5F -8, F.A.G. and shall not operate until it passes a subsequent inspection by the Department. STOP OPERATION ORDER (DACS 03545, Rev. 01/09) # Owner/Manager Signature Inspector's Signature r - -. r i • CHARLES H. BRONSON COMMISSIONER DATA: Date Inspector Event Location Florida Department of Agriculture and Consumer Services Bureau of Fair Rides Inspection AMUSEMENT RIDE INSPECTION REPORT Section 616.242(4), Florida Statutes Rule 5F- 8.0012, Florida Administrative Code Phone (850) 488 -9790; Fax (850) 488 -9023 Ride Owner Ride Name MFG Serial # USAID # Permit # KIDDIE NON - KIDDIE SUPER REQUIREMENTS: (Check each requirement as it is accomplished or place (N) if not applicable) 1. RIDE STATUS a.( ) Permit b.( ) Insurance c.( ) Compliance /NDT d.( ) Manuals 4. ATTACHMENTS a.( ) Gen Attachments b.( ) Carrier/Tubs c.( ) Restraints d.( ) Sweeps DEFICIENCIES: DACS -03419 Rev. 12/09 White /Bureau 2. INSTALLATION a.( ) Blocking b.( ) Fencing /Guarding c.( ) Braces /Guys /Anchors d.( ) Signs e.( ) Electrical 5. OPERATION a.( ) RPM Check b.( ) Controls c.( ) Brakes d.( ) Limit Controls anary / Owner or Manager �' Scheduled Unannounced s 3. STRUCTURAL a.( ) Hydraulics /Pneumatics b.( ) Pins /Bolts /Keys c.( ) Structural Integrity d.( ) Tires/Wheels /Casters e.( ) Bearings /Spindles /Axles f. ( ) Track/Rim Iron 6. OTHER a.( ) Automatic Sprinkler /Smoke Detector b.( ) Water Quality c.( ) Bungy Cords d.( ) Cranes e.( ) Comments Re- inspection — Permit Inspection /Red Tag History Temporary — Permanent Location When Facing: L. R. Inspection of If you wish to contest the Department's action, you have the right to request an administrative hearing to be conducted in accordance with Sections 120.569 and 120.57, Florida Statutes and to be represented by counsel or other qualified representative. Your request for hearing must contain: 1. Your name, address, and telephone number, and facsimile number (if any). 2. The name, address, and telephone number, and facsimile number of your attorney or qualified representative (if any) upon whom service of pleadings and other papers shall be made. 3. A statement that you are requesting an administrative hearing and dispute the material facts alleged by the department, in which case you must identify the material facts that are in dispute (formal hearing), or that you request an administrative hearing and that you do not dispute the facts alleged by the department (informal hearing). 4. A statement of when (date) you received this Notice and the file number of this Notice. Your request for a hearing must be received at the address shown on this Notice within twenty -one (21) days of receipt of this Notice. If you fail to obtain a Release from this Notice or fail to request an administrative hearing within the twenty -one (21) day deadline you waive your right to a hearing and the Department may enter a Final Order imposing up to the maximum penalties as authorized by Florida Law. DACS -03419 Rev. 01/09 Administrative Hearing Available I have read this notice of rights: SIGNATURE OF OWNER DATE ID PURSUANT TO Section 616.242(7), F.S., AN INSPECTION CERTIFICATE IS ISSUED, when box is checked. The above identified amusement ride meets the requirements of Section 616.242, F.S. and Chapter 5F -8, F.A.C. and the deficiencies noted above (if any) have been corrected. INSPECTION CERTFICATE (DACS 03550, Rev. 01/09) # I acknowledge ride is §616.242(16), and the receipt of this inspection report and the NOTICE OF RIGHTS on the reverse side of this form. I certify this amusement in compliance with §616.242, F.S. The employee responsible for operating this ride has been trained in accordance with F.S. and the manufacturers operating instructions or the operating fact sheets for this ride are available to the operator, last 14 daily insp ction repofts were completed and available upon request. f Owner /Manager SignatLtfe Inspector's Signature PURSUANT TO Section 616.242(7), F.S., the above identified amusement ride does not meet the requirements of Section 616.242, F.S. and Chapter 5F -8, F.A.C. and shall not operate until it passes a subsequent inspection by the Department. STOP OPERATION ORDER (DACS 03545, Rev. 01/09) # Owner/Manager Signature Inspector's Signature CHARLES H. BRONSON' COMMISSIONER DATA: Date 4 f- Ride Owner A/ '4 .` ._ Scheduled'- Unannounced Inspector Ride Name "' t 4 Re- inspection - Permit Event MFG Inspection /Red Tag History Location i1 ' ?� " )1 /J Serial # 76 / Temporary- Permanent DEFICIENCIES: RESULTS: DACS -03419 Rev. 12/09 Florida Department of Agriculture and Consumer Services Bureau of Fair Rides Inspection AMUSEMENT RIDE INSPECTION REPORT White /Bureau Section 616.242(4), Florida Statutes Rule 5F- 8.0012, Florida Administrative Code Phone (850) 488 -9790; Fax (850) 488 -9023 USAID # 1 c)/ 9 Location When Facing: Permit #' !� !� ' L. R. KIDDIE NON- KIDDIE SUPER REQUIREMENTS: (Check each requirement as it is accomplished or place (N) if not applicable) 1. RIDE STATUS 2. INSTALLATION 3. STRUCTURAL a.( ) Permit a.( ) Blocking a.( ) Hydraulics /Pneumatics b.( ) Insurance b.( ) Fencing /Guarding b.( ) Pins /Bolts /Keys c.( ) Compliance /NDT c.( ) Braces /Guys /Anchors c.( ) Structural Integrity d.( ) Manuals d.( ) Signs d.( ) Tires/Wheels /Casters e.( ) Electrical e.( ) Bearings /Spindles /Axles f. ( ) Track/Rim Iron 4. ATTACHMENTS 5. OPERATION 6. OTHER a.( ) Gen Attachments a.( ) RPM Check a.( ) Automatic Sprinkler /Smoke Detector b.( ) Carrier/Tubs b.( ) Controls b.( ) Water Quality c.( ) Restraints c.( ) Brakes c.( ) Bungy Cords d.( ) Sweeps d.( ) Limit Controls d.( ) Cranes e.( ) Comments Canary/ Owner or Manager inivtven Inspection of If you wish to contest the Department's action, you have the right to request an administrative hearing to be conducted in accordance with Sections 120.569 and 120.57, Florida Statutes and to be represented by counsel or other qualified representative. Your request for hearing must contain: 1. Your name, address, and telephone number, and facsimile number (if any). 2. The name, address, and telephone number, and facsimile number of your attorney or qualified representative (if any) upon whom service of pleadings and other papers shall be made. 3. A statement that you are requesting an administrative hearing and dispute the material facts alleged by the department, in which case you must identify the material facts that are in dispute (formal hearing), or that you request an administrative hearing and that you do not dispute the facts alleged by the department (informal hearing). 4. A statement of when (date) you received this Notice and the file number of this Notice. Your request for a hearing must be received at the address shown on this Notice within twenty -one (21) days of receipt of this Notice. If you fail to obtain a Release from this Notice or fail to request an administrative hearing within the twenty -one (21) day deadline you waive your right to a hearing and the Department may enter a Final Order imposing up to the maximum penalties as authorized by Florida Law. DACS -03419 Rev. 01/09 Administrative Hearing Available I have read this notice of rights: SIGNATURE OF OWNER DATE CHARLES H. BRONSON COMMISSIONER DATA: Date Inspector Event Location 1. RIDE STATUS a.( ) Permit b.( ) Insurance c.( ) Compliance /NDT d.( ) Manuals 4. ATTACHMENTS a.( ) Gen Attachments b.( ) Carrier/Tubs c.( ) Restraints d.( ) Sweeps DEFICIENCIES: DACS -03419 Rev. 12/09 Florida Department of Agriculture and Consumer Services Bureau of Fair Rides Inspection AMUSEMENT RIDE INSPECTION REPORT Ride Owner Ride Name MFG Y" r Serial # USAID # Permit # White /Bureau Section 616.242(4), Florida Statutes Rule 5F- 8.0012, Florida Administrative Code Phone (850) 488 -9790; Fax (850) 488 -9023 KIDDIE NON - KIDDIE SUPER REQUIREMENTS: (Check each requirement as it is accomplished or place (N) if not applicable) 2. INSTALLATION a.( ) Blocking b.( ) Fencing /Guarding c.( ) Braces /Guys /Anchors d.( ) Signs e.( ) Electrical 5. OPERATION a.( ) RPM Check b.( ) Controls c.( ) Brakes d.( ) Limit Controls i ?, 39 .. - 7 8 Canary / Owner or Manager Scheduled — Unannounced Re- inspection — Permit Inspection /Red Tag History Temporary — Permanent Location When Facing: L. R. 3. STRUCTURAL a.( ) Hydraulics /Pneumatics b.( ) Pins /Bolts /Keys c.( ) Structural Integrity d.( ) Tires/Wheels /Casters e.( ) Bearings /Spindles /Axles f. ( ) Track /Rim Iron 6. OTHER a.( ) Automatic Sprinkler /Smoke Detector b.( ) Water Quality c.( ) Bungy Cords d.( ) Cranes e.( ) Comments Inspection - of _ PURSUANT TO Section 616.242(7), F.S., AN INSPECTION CERTIFICATE IS ISSUED, when box is checked. The above identified amusement ride meets the requirements of Section 616.242, F.S. and Chapter 5F -8, F.A.C. and the deficiencies noted above (if any) have been corrected. INSPECTION CERTFICATE (DACS 03550, Rev. 01/09) # I acknowledge ride is §616.242(16), and the receipt of this inspection report and the NOTICE OF RIGHTS on the reverse side of this form. I certify this amusement in compliance with §616.242, F.S. The employee responsible for operating this ride has been trained in accordance with F.S. and the manufacturers operating instructions or the operating fact sheets for this ride are available to the operator, last 14 daily inspection reports were completed and available upon request. Owner /Manager Signature Inspector's Signature PURSUANT TO Section 616.242(7), F.S., the above identified amusement ride does not meet the requirements of Section 616.242, F.S. and Chapter 5F -8, F.A.C. and shall not operate until it passes a subsequent inspection by the Department. STOP OPERATION ORDER (DACS 03545, Rev. 01/09) # Owner/Manager Signature Inspector's Signature CHARLES H. BRONSON COMMISSIONER DATA: Date Inspector Event Location 1. RIDE STATUS a.( ) Permit b.( ) Insurance c.( ) Compliance /NDT d.( ) Manuals 4. ATTACHMENTS a.( ) Gen Attachments b.( ) Carrier/Tubs c.( ) Restraints d.( ) Sweeps DEFICIENCIES: DACS -03419 Rev. 12/09 Florida Department of Agriculture and Consumer Services Bureau of Fair Rides Inspection AMUSEMENT RIDE INSPECTION REPORT Ride Owner Ride Name MFG Y" r Serial # USAID # Permit # White /Bureau Section 616.242(4), Florida Statutes Rule 5F- 8.0012, Florida Administrative Code Phone (850) 488 -9790; Fax (850) 488 -9023 KIDDIE NON - KIDDIE SUPER REQUIREMENTS: (Check each requirement as it is accomplished or place (N) if not applicable) 2. INSTALLATION a.( ) Blocking b.( ) Fencing /Guarding c.( ) Braces /Guys /Anchors d.( ) Signs e.( ) Electrical 5. OPERATION a.( ) RPM Check b.( ) Controls c.( ) Brakes d.( ) Limit Controls i ?, 39 .. - 7 8 Canary / Owner or Manager Scheduled — Unannounced Re- inspection — Permit Inspection /Red Tag History Temporary — Permanent Location When Facing: L. R. 3. STRUCTURAL a.( ) Hydraulics /Pneumatics b.( ) Pins /Bolts /Keys c.( ) Structural Integrity d.( ) Tires/Wheels /Casters e.( ) Bearings /Spindles /Axles f. ( ) Track /Rim Iron 6. OTHER a.( ) Automatic Sprinkler /Smoke Detector b.( ) Water Quality c.( ) Bungy Cords d.( ) Cranes e.( ) Comments Inspection - of _ Administrative Hearing Available If you wish to contest the Department's action, you have the right to request an administrative hearing to be conducted in accordance with Sections 120.569 and 120.57, Florida Statutes and to be represented by counsel or other qualified representative. Your request for hearing must contain: 1. Your name, address, and telephone number, and facsimile number (if any). 2. The name, address, and telephone number, and facsimile number of your attorney or qualified representative (if any) upon whom service of pleadings and other papers shall be made. 3. A statement that you are requesting an administrative hearing and dispute the material facts alleged by the department, in which case you must identify the material facts that are in dispute (formal hearing), or that you request an administrative hearing and that you do not dispute the facts alleged by the department (informal hearing). 4. A statement of when (date) you received this Notice and the file number of this Notice. Your request for a hearing must be received at the address shown on this Notice within twenty -one (21) days of receipt of this Notice. If you fail to obtain a Release from this Notice or fail to request an administrative hearing within the twenty -one (21) day deadline you waive your right to a hearing and the Department may enter a Final Order imposing up to the maximum penalties as authorized by Florida Law. DACS -03419 Rev. 01/09 I have read this notice of rights: SIGNATURE OF OWNER DATE O PURSUANT TO Section 616.242(7), F.S., AN INSPECTION CERTIFICATE IS ISSUED, when box is checked. The above identified amusement ride meets the requirements of Section 616.242, F.S. and Chapter 5F -8, F.A.C. and the deficiencies noted above (if any) have been corrected. INSPECTION CERTFICATE (DACS 03550, Rev. 01/09) # I acknowledge ride is §616.242(16), and the receipt of this inspection report and the NOTICE OF RIGHTS on the reverse side of this form. I certify this amusement in compliance with §616.242, F.S. The employee responsible for operating this ride has been trained in accordance with F.S, and the manufacturers operating instructions or the operating fact sheets for this ride are available to the operator, last 14 dally inspection reports were completed and available upon request. r Owner /Manager Signature °•- • =- Inspector's Signature PURSUANT TO Section 616 242(7), F.S., the above identified amusement ride does not meet the requirements of Section 616.242, F.S. and Chapter 5F -8, F.A.C. and shall not operate until it passes a subsequent inspection by the Department. STOP OPERATION ORDER (DACS 03545, Rev. 01/09) # Owner/Manager Signature Inspector's Signature CHARLES H. BRONSON COMMISSIONER DATA: Date Inspector Event Location 1. RIDE STATUS a.( ) Permit b.( ) Insurance c.( ) Compliance /NDT d.( ) Manuals 4. ATTACHMENTS a.( ) Gen Attachments b.( ) Carrier/Tubs c.( ) Restraints d.( ) Sweeps DEFICIENCIES: DACS -03419 Rev. 12/09 Florida Department of Agriculture and Consumer Services Bureau of Fair Rides Inspection AMUSEMENT RIDE INSPECTION REPORT White /Bureau Section 616.242(4), Florida Statutes Rule 5F- 8.0012, Florida Administrative Code Phone (850) 488 -9790; Fax (850) 488 -9023 Ride Owner 1 Ride Name MFG Serial # USAID # Permit # 2. INSTALLATION a.( )Blocking b.( ) Fencing /Guarding c.( ) Braces /Guys /Anchors d.( ) Signs e.( ) Electrical 5. OPERATION a.( ) RPM Check b.( ) Controls c.( ) Brakes d.( ) Limit Controls anary / Owner or Manager KIDDIE NON- KIDDIE SUPER REQUIREMENTS: (Check each requirement as it is accomplished or place (N) if not applicable) Scheduled — Unannounced Re- inspection — Permit Inspection /Red Tag History Temporary — Permanent Location When Facing: L. R. 3. STRUCTURAL a.( ) Hydraulics /Pneumatics b.( ) Pins /Bolts /Keys c.( ) Structural Integrity d.( ) Tires/Wheels /Casters e.( ) Bearings /Spindles /Axles f. ( ) Track/Rim Iron 6. OTHER a.( ) Automatic Sprinkler /Smoke Detector b.( ) Water Quality c.( ) Bungy Cords d.( ) Cranes e.( ) Comments Inspection_ of DACS -03419 Rev. 01/09 Administrative Hearing Available If you wish to contest the Department's action, you have the right to request an administrative hearing to be conducted in accordance with Sections 120.569 and 120.57, Florida Statutes and to be represented by counsel or other qualified representative. Your request for hearing must contain: 1. Your name, address, and telephone number, and facsimile number (if any). 2. The name, address, and telephone number, and facsimile number of your attorney or qualified representative (if any) upon whom service of pleadings and other papers shall be made. 3. A statement that you are requesting an administrative hearing and dispute the material facts alleged by the department, in which case you must identify the material facts that are in dispute (formal hearing), or that you request an administrative hearing and that you do not dispute the facts alleged by the department (informal hearing). 4. A statement of when (date) you received this Notice and the file number of this Notice. Your request for a hearing must be received at the address shown on this Notice within twenty -one (21) days of receipt of this Notice. If you fail to obtain a Release from this Notice or fail to request an administrative hearing within the twenty -one (21) day deadline you waive your right to a hearing and the Department may enter a Final Order imposing up to the maximum penalties as authorized by Florida Law. I have read this notice of rights: SIGNATURE OF OWNER DATE ❑ PURSUANT TO Section 616.242(7), F.S., AN INSPECTION CERTIFICATE IS ISSUED, when box is checked. The above identified amusement ride meets the requirements of Section 616.242, F.S. and Chapter 5F -8, F.A.G. and the deficiencies noted above (if any) have been corrected. INSPECTION CERTFICATE (DACS 03550, Rev. 01/09) # I acknowledge ride is §616.242(16), and the receipt of this inspection report and the NOTICE OF RIGHTS on the reverse side of this form. I certify this amusement in compliance with §616.242, F.S. The employee responsible for operating this ride has been trained in accordance with F.S. and the manufacturers operating instructions or the operating fact sheets for this ride are available to the operator, last 14 dai}y inspection reports were completed and available upon request. Owner /Manager Signature 3 Inspector's Signature PURSUANT TO Section 616.242(7), F.S., the above identified amusement ride does not meet the requirements of Section 616.242, F.S. and Chapter 5F -8, F.A.C. and shall not operate until it passes a subsequent inspection by the Department. STOP OPERATION ORDER (DACS 03545, Rev. 01/09) # Owner/Manager Signature Inspector's Signature CHARLES H. BRONSON COMMISSIONER DATA: Date Inspector Event Location Ride Owner Ride Name MFG Serial # USAID # Permit # KIDDIE NON - KIDDIE SUPER REQUIREMENTS: (Check each requirement as it is accomplished or place (N) if not applicable) 1. RIDE STATUS a.( ) Permit b.( ) Insurance c.( ) Compliance /NDT d.( ) Manuals 4. ATTACHMENTS a.( ) Gen Attachments b.( ) Carrier/Tubs c.( ) Restraints d.( ) Sweeps DEFICIENCIES: RESULTS: DACS -03419 Rev. 12/09 Florida Department of Agriculture and Consumer Services Bureau of Fair Rides Inspection AMUSEMENT RIDE INSPECTION REPORT White /Bureau Section 616.242(4), Florida Statutes Rule 5F- 8.0012, Florida Administrative Code Phone (850) 488 -9790; Fax (850) 488 -9023 2. INSTALLATION a.( ) Blocking b.( ) Fencing/Guarding c.( ) Braces /Guys /Anchors d.( ) Signs e.( ) Electrical 5. OPERATION a.( ) RPM Check b.( ) Controls c.( ) Brakes d.( ) Limit Controls Canary/ Owner or Manager Scheduled — Unannounced Re- inspection — Permit Inspection /Red Tag History Temporary Permanent Location When Facing: L. R. 3. STRUCTURAL a.( ) Hydraulics /Pneumatics b.( ) Pins /Bolts /Keys c.( ) Structural Integrity d.( ) Tires/Wheels /Casters e.( ) Bearings /Spindles /Axles f. ( ) Track/Rim Iron 6. OTHER a.( ) Automatic Sprinkler /Smoke Detector b.( ) Water Quality c.( ) Bungy Cords d.( ) Cranes e.( ) Comments inKutven Inspection of DACS -03419 Rev. 01/09 Administrative Hearing Available If you wish to contest the Department's action, you have the right to request an administrative hearing to be conducted in accordance with Sections 120.569 and 120.57, Florida Statutes and to be represented by counsel or other qualified representative. Your request for hearing must contain: 1. Your name, address, and telephone number, and facsimile number (if any). 2. The name, address, and telephone number, and facsimile number of your attorney or qualified representative (if any) upon whom service of pleadings and other papers shall be made. 3. A statement that you are requesting an administrative hearing and dispute the material facts alleged by the department, in which case you must identify the material facts that are in dispute (formal hearing), or that you request an administrative hearing and that you do not dispute the facts alleged by the department (informal hearing). 4. A statement of when (date) you received this Notice and the file number of this Notice. Your request for a hearing must be received at the address shown on this Notice within twenty -one (21) days of receipt of this Notice. If you fail to obtain a Release from this Notice or fail to request an administrative hearing within the twenty -one (21) day deadline you waive your right to a hearing and the Department may enter a Final Order imposing up to the maximum penalties as authorized by Florida Law. I have read this notice of rights: SIGNATURE OF OWNER DATE ❑ PURSUANT TO Section 616.242(7), F.S., AN INSPECTION CERTIFICATE IS ISSUED, when box is checked. The above identified amusement ride meets the requirements of Section 616.242, F.S. and Chapter 5F -8, F.A.C. and the deficiencies noted above (if any) have been corrected. INSPECTION CERTFICATE (DACS 03550, Rev. 01/09) # I acknowledge ride is §616.242(16), and the receipt of this inspection report and the NOTICE OF RIGHTS on the reverse side of this form. 1 certify this amusement in compliance with §616.242, F.S. The employee responsible for operating this ride has been trained in accordance with F.S. and the manufacturers operating instructions or the operating fact sheets for this ride are available to the operator, last 14 daily inspection reports were completed and available upon request. Owner/Manager Signature Inspector's Signature PURSUANT TO Section 616.242(7), F.S., the above identified amusement ride does not meet the requirements of Section 616.242, F.S. and Chapter 5F -8, F.A.C. and shall not operate until it passes a subsequent inspection by the Department. STOP OPERATION ORDER (DACS 03545, Rev. 01/09) # Owner/Manager Signature Inspector's Signature CHARLES H. BRONSON- COMMISSIONER DATA: Date Inspector Event Location 4-- ;' Florida Department of Agriculture and Consumer Services Bureau of Fair Rides Inspection AMUSEMENT RIDE INSPECTION REPORT Section 616.242(4), Florida Statutes Rule 5F- 8.0012, Florida Administrative Code Phone (850) 488 -9790; Fax (850) 488 -9023 Ride Owner Ride Name .ro MFG r ?rr a .01 Serial # ` USAID # Permit # 7 KIDDIE NON - KIDDIE SUPER REQUIREMENTS: (Check each requirement as it is accomplished or place (N) if not applicable) 1. RIDE STATUS a.( ) Permit b.( ) Insurance c.( ) Compliance /NDT d.( ) Manuals 4. ATTACHMENTS a.( ) Gen Attachments b.( ) Carrier/Tubs c.( ) Restraints d.( ) Sweeps DEFICIENCIES: DACS -03419 Rev. 12/09 White /Bureau 2. INSTALLATION a.( ) Blocking b.( ) Fencing /Guarding c.( ) Braces /Guys /Anchors d.( ) Signs e.( ) Electrical 5. OPERATION a.( ) RPM Check b.( ) Controls c.( ) Brakes d.( ) Limit Controls Canary / Owner or Manager Scheduled — Unannounced Re- inspection — Permit Inspection /Red Tag History Temporary — Permanent Location When Facing: L. R. 3. STRUCTURAL a.( ) Hydraulics /Pneumatics b.( ) Pins /Bolts /Keys c.( ) Structural Integrity d.( ) Tires/Wheels /Casters e.( ) Bearings /Spindles /Axles f. ( ) Track/Rim Iron 6. OTHER a.( ) Automatic Sprinkler /Smoke Detector b.( ) Water Quality c.( ) Bungy Cords d.( ) Cranes e.( ) Comments Inspection ofL DACS -03419 Rev. 01/09 Administrative Hearing Available If you wish to contest the Department's action, you have the right to request an administrative hearing to be conducted in accordance with Sections 120.569 and 120.57, Florida Statutes and to be represented by counsel or other qualified representative. Your request for hearing must contain: 1. Your name, address, and telephone number, and facsimile number (if any). 2. The name, address, and telephone number, and facsimile number of your attorney or qualified representative (if any) upon whom service of pleadings and other papers shall be made. 3. A statement that you are requesting an administrative hearing and dispute the material facts alleged by the department, in which case you must identify the material facts that are in dispute (formal hearing), or that you request an administrative hearing and that you do not dispute the facts alleged by the department (informal hearing). 4. A statement of when (date) you received this Notice and the file number of this Notice. Your request for a hearing must be received at the address shown on this Notice within twenty -one (21) days of receipt of this Notice. If you fail to obtain a Release from this Notice or fail to request an administrative hearing within the twenty -one (21) day deadline you waive your right to a hearing and the Department may enter a Final Order imposing up to the maximum penalties as authorized by Florida Law. I have read this notice of rights: SIGNATURE OF OWNER DATE BUILDING PERMIT APPLICATION FBC 2004 Permit Type: Mechanical Owner's Name (Fee Simple Titleholder) Owner's Address 9 401 B i s c a n CityMiami Shores State City Miami Describe Work: Amuse Miami Shores Village Building Department /0050 N.E.2nd Avenue, Miami Shores, Florida 33138 Tel: (305) 7952204 Fax: (305) 756.8972 Archdiocese of Miami FL Tenant/Lessee Name E - MAIL: Job Address (where the work is being done) 418 N.E. 1 0 5 S t re 't City Miami Shores Village County Miami -Dade FOLIO / PARCEL # Is Building Historically Designated YES Contractor's Company Name Modern Contractor's Address 10420 S W 115 Qualifier Name Brian Morrissey State Certificate or Registration No. n / a E - MAIL: bmorri9495 @aol _rrrn Architect/Engineer's Name (if applicable) Phone # Value of Work For this Permit $ 250. Type of Work: ❑Addition ['Alteration Midways, Street State FL Submittal Fee $ Permit Fee $ Notary $ Scanning $ Radon $ NO Inc. Training/Education Fee $ Bond $ Code Enforcement $ Structural Review. $ Zip 33138 Permit No. Master Permit No. Phone# (305) 757 -6241 St. Rose of Lima Cathcl i r ch„rrphone# ( 305) 758 -0537 Zip 33138 Phone# (305) 234 -7776 Zip 33176 Phone# (305) 214 -777& Certificate of Competency No. n / a k iig r l S. JAN BY: ..... r :R` 77 2010 Square / Linear Footage Of Work: :New .e- . .- flOe ***** * * * * * * * * * * * * * * * * * * * * * * * * * * * * * ** *fir . i ..******* k****** *** * * ** ** * ** * * **** ** ** ** *** ** V ✓ CCF $ CO /CC DPBR $ ❑ Repair/Replace ❑ Demolition _ Jan. 28 -30, 2011 Technology Fee $ Zoning $ Double Fee $ Total Fee Now Due $ See Reverse side — Bonding Company's Name (if applicable) Bonding Company's Address City State Zip Mortgage Lender's Name (if applicable) Mortgage Lender's Address City State Zip Application is hereby made to obtain a permit to do the work and installations as indicated. I certify that no work or installation has commenced prior to the issuance of a permit and that all work will be performed to meet the standards of all laws regulating construction in this jurisdiction. I understand that a separate permit must be secured for ELECTRICAL WORK, PLUMBING, SIGNS, WELLS, POOLS, FURNACES, BOILERS, HEATERS, TANKS and AIR CONDITIONERS, ETC OWNER'S AFFIDAVIT: I certify that all the foregoing information is accurate and that all work will be done in compliance with all applicable laws regulating construction and zoning. "WARNING TO OWNER YOUR FAILURE TO RECORD A NOTICE OF COMMENCEMENT MAY RESULT IN YOUR PAYING TWICE FOR IMPROVEMENTS TO YOUR PROPERTY. IF YOU INTEND TO OBTAIN FINANCING, CONSULT WITH YOUR LENDER OR AN ATTORNEY BEFORE RECORDING YOUR NOTICE OF COMMENCEMENT." Notice to Applicant: As a condition to the issuance of a building permit with an estimated value exceeding $2500, the applicant must promise in good faith that a copy of the notice of commencement and construction lien law brochure will be delivered to the person whose property is subject to attachment Also, a certi copy of the recorded notice of commencement must:be posted at the job site for the first inspection which occurs seven (7) days after the building permit is issued In the absence of such posted notice, the inspection will not be app a greinspection fee will be charged Signature / - ccC (Revised 02/08/06) Owner or Ag The foregoing instrument was acknowledged before me this 6 day of 4L0 /D, by d Aeg-14,5 sot-A./irks , who is personally known to me or who has produced �oe.�g �61 ivEW 104 s identification and who did take an oath. NOTARY PUBLIC: Signature ( . Contractor The foregoing instrument was acknow edged before a this day of f ,20 ,by AN ri L-NK- who is personally known to me or who has produced (P as identification and who did take an oath. NOTARY PUBLIC: Sign: Print . \� c., . My Commission Expires: _ o . " .. ' `s o �' '`' : m ir t ',� ® ' £x8nniner��� ' � /Lll 1�1►111 En Zoning t THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR INSRD TYPE OF INSURANCE POLICY NUMBER DATE tMM/DD/W1 DATE EXPIRATION ON LIMITS INSURED Briggs Transport, Inc. DBA: Modern Midways, Inc. 22901 Sherman Road Steger, IL 60475 A 12866 GENERAL LIABILITY COMMERCIAL GENERAL LIABILITY CPP0100902 -00 04/03/2010 04/03/2011 EACH OCCURRENCE $ 1,000,000 X DAMAGE TO RENTED PRFMISFS (Fa mrimama) $ CLAIMS MADE X OCCUR MED EXP (My one person) $ PERSONAL & ADV INJURY $ 1 000,000 GENERAL AGGREGATE $ 2,000,000 GENI AGGREGATE LIMIT APPLIES PER: POLICY n JEC n LOC PRODUCTS - COMP /OP AGG $ 1 000, 000 — I AUTOMOBILE WABILITY ANY AUTO ALL OWNED AUTOS SCHEDULED AUTOS HIRED AUTOS NON -OWNED AUTOS CPP0100902 -00 05/27/2010 04/03/2011 COMBINED SINGLE LIMIT (Ea accident) $ 1,000,000 BODILY INJURY (Per person) $ X X BODILY INJURY (Per accldent) $ X PROPERTY DAMAGE (Per accident) $ GARAGE LIABILITY ANY A U T O AUTO ONLY - EA ACCIDENT $ OTHER THAN EA ACC $ 1 AUTO ONLY: AGG $ A EXCESS/UMBRELLA LIABILITY ELP0010210 - 00 04/03/2010 04/03/2011 EACH OCCURRENCE $ 4,000,000 " I OCCUR CLAIMS MADE AGGREGATE $ 4,000,000 DEDUCTIBLE RETENTION $ $ $ $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? If yes, describe under SPECIAL PROVISIONS below TORYT MITS I I O FR EL. EACH ACCIDENT $ EL DISEASE - EA EMPLOYEE $ EL DISEASE - POLICY LIMIT $ OTHER DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES / EXCLUSIONS ADDED BY ENDORSEMENT / SPECIAL PROVISIONS St. Rose of Lima Catholic Church & School; Archdiocese of Miami; Archbishop Thomas G. Wenski; Village of Miami Shores, Florida are included as additional insureds but only as respects the operation of the named insured per policy terms and conditions. Event Dates: January 28 -31, 2011 ACORD CERTIFICATE OF LIABILITY INSURANCE DATE(M61/DD/YYYY) 08/16/2010 AUTHOR ED REPRESENTATIVE �9 Dave Harman /JOANNE Lam'" / " �''"' t.ga- " --- PRODUCER (425) 454 -3386 FAX (425) 451 -3716 Arthur J. Gallagher Risk Management Services, Inc. P .0. Bos 367 Bellevue, WA 98009 -0367 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. INSURERS AFFORDING COVERAGE NAIC # INSURED Briggs Transport, Inc. DBA: Modern Midways, Inc. 22901 Sherman Road Steger, IL 60475 INSURER A: T.H.E. Insurance Company 12866 INSURER B: INSURER C: INSURER D: INSURER E: Village of Miami Shores c/o Builidng Department 10050 NE 2nd Avenue Miami Shores, FL 33138 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR REPRESENTATIVES. AUTHOR ED REPRESENTATIVE �9 Dave Harman /JOANNE Lam'" / " �''"' t.ga- " --- ACORD 25 (2001/08) © ACORD CORPORATION 1988 PRODUCER INSURED 203 -931 -7095 Specialty Insurance, LTD -Tom Plouffe P.O. Box 16901 West Haven, CT 06516 MODERN MIDWAYS, INC. 879 JOLIET STREET DYER, IN 46377 COVERAGES THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED, NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS. EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. co LTR TYPE OF INSURANCE GENERAL LIABILITY COMMERCIAL GENERAL LIABILITY CLAIMS MADE OCCUR OWNER'S & CONTRACTOR'S PROT AUTOMOBILE LIABILITY ANY AUTO ALL OWNED AUTOS SCHEDULED AUTOS HIRED AUTOS NON -OWNED AUTOS GARAGE LIABILITY ANY AUTO EXCESS LIABILITY UMBRELLA FORM OTHER THAN UMBRELLA FORM WORKERS COMPENSATION AND EMPLOYERS' LIABILITY THE PROPRIETOR/ PARTNERSIEXECUTIVE OFFICERS ARE OTHER X CERTIFICATE HOLDER INCL EXCL Miami Shore Village c/o Building Department 10050 NE 2nd Avenue Miami Shores, FL 33138 POLICY NUMBER 6KUB- 0329N38- A -10-IN DESCRIPTION OF OPERATIONS ILOCATIONSIVEHICLES /SPECULL ITEMS THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. COMPANY TRAVELERS INDEMNITY COMPANY A COMPANY B COMPANY C COMPANY D POLICY EFFECTIVE DATE (MMIDDIYY) 2/8/10 COMPANIES AFFORDING COVERAGE POLICY EXPIRATION DATE (MMIDDIYY) 2/8/11 CANCELLATION GENERAL AGGREGATE $ PRODUCTS - COMP /OP AGG $ PERSONAL & ADV INJURY $ EACH OCCURRENCE $ FIRE DAMAGE (Any one fire) $ MED EXP (Any one person) $ COMBINED SINGLE LIMIT BODILY INJURY (Per pew) BODILY INJURY (Perecddent) PROPERTY DAMAGE AUTO ONLY - EA ACCIDENT OTHER THAN AUTO ONLY: EACH ACCIDENT AGGREGATE EACH OCCURRENCE AGGREGATE WC STATU- TORY LIMITS EL EACH ACCIDENT X EL DISEASE - POLICY LIMIT LIMITS OTH- ER EL DISEASE - EA EMPLOYEE $ $ 1,000,000 1,000,000 1,000,000 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING COMPANY WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR UABILITY OF ANY KIND UPON THE COMPANY, ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE Thomas A. Plouffe ACORD CORPORATION 1988