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MC-12-52Inspection Worksheet Miami Shores Village 10050 N.E. 2nd Avenue Miami Shores, FL Phone: (305)795 -2204 Fax: (305)756 -8972 Inspection Number: INSP- 168708 Permit Number: MC-1 -12-52 Scheduled Inspection Date: January 27, 2012 Inspector: Perez, JanPierre Owner: CHURCH, ST ROSE OF LIMA CATHOLIC Job Address: 418 NE 105 Street Miami Shores, FL Project: <NONE> Contractor: MODERN MIDWAYS Permit Type: Mechanical - Commercial Inspection Type: Final Work Classification: Addition /Alteration Phone Number (305)758 -0539 Parcel Number 1122310150060 O Phone: (305)234 -7776 Building Department Comments AMUSEMENT RIDES FOR TEMPORARY CHURCH CARNIVAL JAN 27- 29/2012 ( �fZ Inspector Comments Passed Failed Correction Needed Re- Inspection Fee No Additional Inspections can be scheduled until re- inspection fee is paid. January 26, 2012 For Inspections please call: (305)762 -4949 Page 10 of 17 ADAM H. PUTNAM 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 /CiSU-uos NON- REQUIREMENTS: (dhe Phone (850) 921 -1530; Fax (850) 921-1539 Ride Owner 4105er 0%.,) f c 4111Ittill - Unannounced Ride Name Pr,v+) t ie" RJ i Re- inspection — Permit MFG .. , AA. i Inspection/Red Tag History Serial # 0 Q1 .� ` �..: Permanent USAID # 1 \- Location When Facing: Permit # +A t L. Q.P. tt< R. `,*'b+ KIDDIE SUPER ck each requirement as it is accomplished or place (N) if not applicable) 2. IN FALLATION ' 3. STR a. ocking b.( F cing /Guarding c. (ces /Guys /Anchors d.( e.( 1. RID S TATUS a.( rmit b.( surance c.( mpliance /NCT d.(4 Manuals 4. .T ACHMENTS a.9en Attachments b.( ''jrrier/Tubs c.( straints d.( Sweeps DEFICIENCIES: Iectrical 5. OP TION a. ' M Check b.( Qpntrols c.( `'Br kes d.( tmit Controls a.( b•( d. e.( f. TURAL draulics /Pne utics' /Bolts /Keys'' ructural Integrity res/Wheels /Cante rs arings /Spind rack/Rim Iron 6. OT ER a. torrmatic Sprin b. t -ater Quality c.( Fungy Cords d.( anes e.( Comments Detector RESULTS: DACS -03419 Rev. 3/11 White /Bureau Canary/ Owner or Manager Pink/Event Gold /Inspector Inspection PURSUANT TO ection 616.242(7), F.S., AN INSPECTION CERTIFICATE IS ISSUED, when box is checked. The above identified aauser ent ride meets the requirements of Section 616.242, F.S. and Chapter 5F -8, F.A.C. and the deficiencies noted above (if arid!) have been corrected. INSPECTION CERTFICATE (DACS 03550, Rev. 01/09) # , 1`79 40.1- 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 compl' nce with §616.242, F.S. The employee responsible for operating this ride has been trained in accordance with F, . and the manufacturers operating instructions or the operating fact sheets for this ride are available to the operator, last 14;dai i specti• r- •orts were completed and available upon request. r"% Owner anger Sign. re Inspec or's S gnature PURS NT TO Sec ' . a . 16.242(7), F.S., the above identified amusement ride does not meet the requirements of Section 616.24 , 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. 12/09) # Owner /Manager Signature Inspector's Signature DACS -03419 Rev. 3/11 White /Bureau Canary/ Owner or Manager Pink/Event Gold /Inspector 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. I have read this notice of rights: SIGNATURE OF OWNER DATE DACS -03419 Rev. t:.1 ADAM H. PUTNAM COMMISSIONER DATA: Date Inspector Event Location KIDDIE 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) 921 -1530; Fax (850) 921 -1539 . if sv�.! o IE Ride Owner Ride Name MFG Serial # USAID # Permit # SUPER Mober / i+ Y ‘h v w1� c:0 L \►-e % o - Unannounced Re- inspection — Permit Inspection /Red Tag History ry — Permanent Location When Facing: :i'p* • REQUIREMENTS: (Check each requirement as it is accomplished or place (N) if not applicable) 1. RIDE STATUS a.(#01" mit b.(urance c.(mpliance /NDT d.(.• Manuals 4. AT ,ACHMENTS a.( yen Attachments b.( ner/Tubs c.( 516straints d.( ArSweeps DEFICIENCIES: 2. INS a.( cking b.( cing /Guarding c.( ces /Guys /Anchors d.( 1 Erecs e.( Electrical R. LLATION . 3. STICTURAL draulics /Pneumatics 5.OP RATION a.K M Check b.( trols c.( es d.( imit Controls 4 b„(sjP,ia'rs /Bolts/Keys c.( ructural Integrity d: es/Wheels /Casters e.( arings /Spindles /Axles. f. ( rack/Rim Iron 6. OT a. utomatic Sprinkle /Smoke Detector b. ater Quality c. ungy Cords d. anes e.( omments RESULTS: Rev. 3/11 White /Bureau Canary/ Owner or Manager Pink/Event Gold /Inspector 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 3,17"37 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 compliant with §616.242, F.S. The employee responsible for operating this ride has been trained in accordance with F.S. an the - manufacturers operating instructions or the operating fact sheets for this ride are available to the operator, last 14 daily i p ction ..., were completed and available upon request. X ner /Ma ger ignatur•""` Inspector's Signature PURSUAN TO Sectio 616 42(7), F.S., the above identified amusement ride does not meet the requirements of',` 616.242, .S. and Chapter F -8, F.A.C. and shall not operate until it passes a subsequent inspection by. the Depart z,Yl STOP OPERATION ORDER (DACS 03545, Rev. 12/09)'# Owner /Manager, Signature Inspector's Signature Rev. 3/11 White /Bureau Canary/ Owner or Manager Pink/Event Gold /Inspector 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. I have read this notice of rights: SIGNATURE OF OWNER DATE DACS -03419 Rev. 3/11 ADAM H. PUTNAM 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 Si 4k4a "J Phone (850) 921 -1530; Fax (850) 921 -1539 Ride Owner Mon n 1 .J )1/4441.04k Ride Name MFG Serial # USAID # Permit # 010 d — Unannounced Re- inspection — Permit Inspection /Red Tag History "" - Permanent Location When Facing: L. jf1) Ft' R. Otto KIDDIE NON - KIDDIE REQUIREMENTS: (Check each requirement as it is accomplished or place (N) if not applicable) 1. 71:11tp STATUS •ALLATION 3. ST CTURAL raulics /Pneumatics ins /Bolts /Keys t1 uctural Integrity rtes/Wheels /Casters t"arings /Spindles/Axles rack/Rim Iron a.( rmit b.( urance o .( mpliance /NDT d.( anuals 4. AT CHMENTS a.( n Attachments b.( rrier/Tubs c.(straints d.( Sweeps DEFICIE CIES: 2. IN a.( cking b.( ncing /Guarding c.( ces /Guys /Anchors d.(ns e.( Electrical 5. OP TION a.( PM Check b.(ontrols c.( djpakes d.( Limit Controls -t C a.( b.( c.( d.( e.( f. ( 6. OT ER a. tomatic Sprinkler /Smoke Detector b.( ater Quality c.(ngy Cords e.( nes cra e.( Comments S AI t RESULTS: DACS -03419 Rev. 3/11 White /Bureau Canary/Owner or Manager Pink/Event Gold /Inspector Inspection _ o PURSUANT TO Section identified amusement noted above (if arty) 616.242(7), F.S., AN INSPECTION CERTIFICATE IS ISSUED, when box is checked. The above ride meets the requirements of Section 616.242, F.S. and Chapter 5F -8, F.A.C. and the deft iencies have been corrected. INSPECTION CERTFICATE (DACS 03550, Rev. 01/09) # / 1 acknowledge ride is §616.242(16), and the receipt of this in compliance with F.S. ., i the last 14 dail in.p -ctio inspection report and the NOTICE OF RIGHTS on the reverse side of this form. 1 certify tibis amusement §616.242, F.S. The employee responsible for operating this ride has been trained in accordance with •manufacturers operating instructions or the operating fact sheets for this ride are available to the operator, ` eo S "-re completed and available upon request. Own- /Ma - EREM tIVAllb Ins. ctor's Si•na ure PURSUAN TO Section j (7), F.S., the above identified amusement ride does not meet the requirements of Sew 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. 12/09) # Owner/Manager g Signature Inspector's Signature DACS -03419 Rev. 3/11 White /Bureau Canary/Owner or Manager Pink/Event Gold /Inspector Inspection _ o 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. have read this notice of rights: SIGNATURE OF OWNER DATE DACS -03419 Rev. 3141 ADAM H. PUTNAM COMMISSIONER DATA: Date Inspector Event Location KIDDIE 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) 921 -1530; Fax (850) 921 - 1539 1_ 1 L Ride Owner M o, T nl M t AtodAy 4-4/A r•> Ride Name ,+pt iC Pots, MFG p' . Y.'S"'f- it (,,,. Serial # rI Iq q S „)‘(t4.171 �'- USAID #" Permit # IE SUPER WLve «d\ - Unannounced Re- inspection — Permit Inspection /Red Tag History Permanent Location When Facing: L. 01 ) R. REQUIREMENTS: (Check each requirement as it is accomplished or place (N) if not applicable) 1. RIDS STATUS a.( rmit b.(urance c.( mpliance /NDT d.( Manuals 4. AT HMENTS a.( -n Attachments b.( rrier/Tubs c.( traints d.( weeps DEFICIENCIES: 2. IN LLATION a. .eking b.( F cing /Guarding c.( ces /Guys /Anchors d.( s e.( lectrical 5. OPE TION a.( M Check b.( trots c.( kes d.( imit Controls I rJ ` ' ' Ck 4 rt +•. i c jp� 3. S;OCTURAL a.( ,Irlydraulics /Pneumatics b.( c.( d.( e.( f. ( P' /Bolts /Keys ctural Integrity es eels /Casters rings /Spindles /Axles Track/Rim Iron 6. OT ER a automatic Sprinkler/Smoke Detector later Quality ungy Cords lanes omments b.(• c.( d.( e.( CAa NQ r t✓ Ns, RESULTS: White /Bureau Canary/ Owner or Manager Pink/Event Gold /Inspector 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 CERTFIGATE (DACS 03550, Rev. 01109) # 11`1411.1 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/id the manufacturers operating instructions or the operating fact sheets for this ride are available to the operator, last 14 daily pection'reports were completed and available upon request. t coss) Owner/ nager i. lns ector's Signature PURSU NT TO Se - 16.242(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. 12/09) # Owner /Manager Signature Inspector's. Signature White /Bureau Canary/ Owner or Manager Pink/Event Gold /Inspector 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. have read this notice of rights: SIGNATURE OF OWNER DATE DACS -03419 Rev. ADAM H. PUTNAM 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) 921 -1530; Fax (850) 921 -1539 1- r,,,,S^'� (M e s c► ,./ S?" k o 4, diagra NON- KIDDIE Ride Owner Ride Name MFG Serial # USAID # Permit # SUPER /A I / – Unannounced c -Tot t I Location When Facing: L. F i'C t R. 'l` r Re- inspection - Permit Inspection /Red Tag History Te Permanent REQUIREMENTS: (Check each requirement as it is accomplished or place (N) if not applicable) 1. RID &' STATUS 2. INS LLATION a.( rmit b.( jpsurance c.( mpliance /NDT d.( Manuals 4. ATi4CHMENTS a. n Attachments b.( a ier/Tubs c.( straints d.( Sweeps DEFICI CIES: (-3R X.0 A V a.( b.( c.(, d.( e.(. eking F cing /Guarding aces/Guys/Anchors ns Electrical 5. OP a.( b.F c.( d.( tATION M Check ntrols Ifces Limit Controls Q I r C 3. ST CTURAL a.( draulics /Pneumatics b.( s /Bolts /Keys c.( ctural Integrity d.( s/Wheels /Casters e.( wrings /Spindles /Axles f. ( Tra&/Rim Iron 6. OT R a. tomatic Sprinkler /Smoke Detector b. ater Quality c.(40B ngy Cords d. apes e.( omments VkSS% Ifi IN kik) 4, .) (10\14 ode% tti t t RESULTS: )5( 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 —6.1°11 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. ari the ,anufacturers operating instructions or the operating fact sheets for this ride are available to the operator, last 14 daily in pection r s wer ompleted and available upon request. } Ownei /Ma ger Signature Inspector's Signature PURSUAN TO Section • ), F.S., the above identified amusement ride does not meet the requirements of Section 616.242, F.S. and Chapter F -8, F.A.C. and shall not operate until it passes a subsequent inspection by the Department' STOP OPERATION ORDER (DACS 03545, Rev. 12/09) Owner /Manager Signature Inspector's Signature DACS -03419 Rev. 3/11 White /Bureau Canary/ Owner or Manager Pink/Event Gold /Inspector lnspecti 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 DACS -03419 Rev. ADAM H. PUTNAM 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 Si .44/S0 S"r- R OS C. Phone (850) 921 -1530; Fax (850) 921 -1539 Ride Owner Ride Name MFG Serial # USAID # Permit # KIDDIE NZVMDIE SUPER REQUIREMENTS: (Check each requirement as it is accomplished or place (N) if not applicable) Mote rJ M' 4WC 9± ed — Unannounced r Re- inspection — Permit (4„'14 1 IA c,-0 Inspection /Red Tag History i #--S901/311%.'i 17 — Permanent 1 0 :Q Location When Facing: 4-' 0%45' \ L. Spit b -1 R. 1. RI STATUS a.( ermit; b.( surance mpliance /NDT d.( Manuals 4. AJ7ACHMENTS a.( "en Attachments b.( arrier/Tubs c.( straints d.( Sweeps DEFICIENCIES: v 2. IN ALLATION 3. ST ^ CTURAL a. y ; raulics /Pneumatics b. . s /Bolts /Keys c.( ructural Integrity d. 'res/Wheels /Casters e.( rings/Spindles /Axles f. ( rack/Rini Iron 6. OT ER a. }utomatic Sprinkler /Smoke Detector a.(4j /Pocking b. (,ncing /Guarding c.( aces /Guys /Anchors d.( ns e.( Electrical 5. OP RATION a.(, $ PM Check b.(•.'tontrols c.( akes d.( imit Controls t4 b.( ter Quality c.( ungy Cords d.( canes e.( Comments RESULTS: DACS -03419 Rev. 3/11 White /Bureau - Canary/ Owner or Manager Pink/Event Gold /Inspector 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 beencorrected. INSPECTION CERTFICATE (DACS 03550, Rev. 01/09) # / B `74 3 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. and the rnufacturers operating instructions or the operating fact sheets for this ride are available to the operator, last 14 iIJ i spe '• r- +orts were completed and available upon reque I 1 SwsJ 0yv er/ anager S' Inspector s Signature PURSU T TO ' 616.242(7), F.S.; the above identified amusement ride does not meet the requirements of Section 616.24 , 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. 12/09) # . Owner /Manager Signature Inspector's Signature DACS -03419 Rev. 3/11 White /Bureau - Canary/ Owner or Manager Pink/Event Gold /Inspector 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 DACS -03419 Rev. PA • ADAM H. PUTNAM COMMISSIONER DATA: Date inspector Event Location ..1111"1 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 t40t &Q Phone (850) 921 -1530; fax (850) 921 -1539 Ride Owner Ride Name MFG Serial # USAID # Permit # NON - KIDDIE SUPER M oLe / M I whys -2-Pc Pk io -% c6 Unannounced Re- inspection - Permit Inspection /Red Tag History - Permanent Location When Facing: L. E7 VC') R. REQUIREMENTS: (Check each requirement as it is accomplished or place (N) if not applicable) 1. RIDE STATUS 2. INS LLATION a.( b.( c.( ermit fsurance ompliance /N DT d.( ") Manuals 4.. AT HMENTS a,( n Attachments b.( arrier/Tubs c.( straints d.( Sweeps DEFICIENCIES:. a.( b.( c.( d.( e.( ocking F cing /Guarding races /Guys /Anchors yes Electrical 5.OP a. b. TION M Check ntrols c.( rakes d.( Limit Controls 3. STRIJCTURA a.( b.( c.( d.( e.( f. yd ra u l ics /Pneumatics P' s /Bolts /Keys uctural Integrity s/Wheels /Casters wrings /Spindles /Axles rack/Rim Iron 6. OT R a.( b. ater Quality . c.( ungy Cords d.( canes e.( omments A utomatic Sprinkler /Smoke Opt RESULTS: Jc1$S N DACS -03419 Rev. 3/11 White /Bureau Canary/ Owner or Manager Pink/Event Gold /Inspector 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 `: nd the anufacturers operating instructions or the operating fact sheets for this ride are available to the operator, last 14 d. i pe• on . -.orts were completed and available upon reques IAA J Ow er/ i . n.. tr Sig - e InsPector's Signature PURSU T TO Se 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. 12/09) Owner /Manager. Signature '' Inspector's Signature DACS -03419 Rev. 3/11 White /Bureau Canary/ Owner or Manager Pink/Event Gold /Inspector 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 DACS -03419 Rev..,...._ ADAM H. PUTNAM 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 J bS Phone (850) 921 -1530; Fax (850)921 -1539 Ride Owner Ride Name MFG Serial # USAID # Permit # KIDDIE IE SUPER Mo09r4 N114WA' C" yr k 04 e.,. dul - Unannounced Re- inspection — Permit Inspection /Red Tag History — Permanent Location When Facing: mpor REQUIREMENTS: (Check each requirement as it is accomplished or place (N) if not applicable) 1. RID STATUS a.( rmit b.( Ipsurance c.( mpliance /NDT d.( Manuals 4 AT�4CHMENTS n Attachments b.(r 'er/Tubs c.( straints d.( Sweeps 2 a. b. d. .'INS ° LLATION • eking ( F cing /Guarding ( ces /Guys /Anchors ( s e.( lectrical 5. OP TION a. c" M Check b.( ' . trots c.( akes d.( Limit Controls DEFICIENCIES: 0 4 .:JA 3. STR TURAL a.( raulics /P ne' umatics b.( s /Bolts /Keys c.( ctural Integrity d.( jotres/VV heels /Casters e.( arings /Spindles /Axles f. (4 Track/Rim Iron OT ER a jecitomatic Sprinkler/Smoke Detector b.ef ater Quality c.( ngy Cords d.( nes e.( omments RESULTS: IL 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 27f 31, 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. a the rsanufacturers operating instructions or the operating fact sheets for his ride are available to the operator, last 14 daily, n p ction re were completed and available upon re uest. wnerMa Or i; nat Inspect is Signature PURSUA TO Sect' s. 42(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. 12/09) # Owner /Manager Signature Inspector's Signature DACS- 03419 Rev. 3/11 White /Bureau Canary/ Owner or Manager Pink/Event Gold/Inspector 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. I have read this notice of rights: SIGNATURE OF OWNER DATE DACS-03419 Rev. __, ` ADAM H. PUTNAM COMMISSIONER 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 DATA: Date Event . f o Location % Li 0 j (4 USAID # 1 "3 1 t Permit# -).. E NON- KIDDIE SUPER Phone (850) 921 -1530; Fax (850) 921 -1539 Ride Owner MObFret miAtAhly S► Ride Name <9 t tik a hi 1 rA a , MFG V ! A+7l/r Serial # S. j rfl "` Unannounced Re- inspection - Permit Inspection /Red Tag History T pora - Permanent Location When Facing: L. R.Z)k REQUIREMENTS: (Check each requirement as it is accomplished or place (N) if not applicable) 1. 1 STATUS 2. IN ALLATION a.( rmit a. b.( urance b.( c.(mpliance /NDT c.( d.( anuals d.( e.( 4. A CH ENTS en Attachments b.(- ier/Tubs' c.( estraints d.( Sweeps DEFICIENCIES:' eking F cing /Guarding ces /Guys /Anchors lectrical 5. OP ` - TION a. f' M Check b.( ontrols c.( akes d.( Limit Controls 3. ST UCTURAL a. draulics /Pneumatics b.(s /Bolts /Keys c.(ir ctural Integrity d.( /Wheels /Casters e.( rings /Spindles /Axles f. ( rack/Rim Iron 6. OT R a`( tomatic Sprinkler /Smoke Detector b. ater Quality .. c.( c ungy Cords d. nes e.( omments RESULTS: 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) # / X79 34. Ct4 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 §619.242, F.S. The employee responsible for operating this ride has been trained in accordance with §616.242(16), F.S. _. the rtrufacturers operating instructions or the operating fact sheets for this ride are available to the operator, and the last 14 dail n .pgction y. were completed and available upon request Inspector's Signature PURSUAN TO Section •.242(7), F.S., the above identified amusement ride does not meet the requirements of Section 6.16.242, 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. :12 /09)' Owner/Manager Signature Inspector's Signature DACS -03419 Rev. 3/11 White /Bureau Canary/ Owner or Manager Pink/Event Gold /Inspector inspection Vff 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 DACS -03419 Rev. ADAM H. PUTNAM COMMISSIONER DATA: 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) 921 -1530; Fax (850)921 -1539 Date w-, , "" 1 -- Ride Owner Inspector 1 44 G3 Ride Name fv Event vi MFG Location Serial # USAID # Permit # So V. .p Unannounced Re- inspection - Permit Inspection /Red Tag History mpora — Permanent Loc tion When Facing: L, ‘4,40? R. .5tkkb4.r KIDDIE NON- KIDDIE REQUIREMENTS: (Check each requirement as it is accomplished or place (N) if not applicable) 1. RI! TATUS 2. INSTALLATION 3. STRUCTURAL a. -rM b. urance c.( pliance/NDT d.( Manuals 4. A CHMENTS a. n Attachments b.( rrier/Tubs c.( taints d.( weeps DEFICIENCIES: a.4 b.( c.( d.( e.( 5.OP a.("! b.(4 c•( d.( .+)'"I ticking lancing /Guarding Ices /Guys /Anchors hs lectrical TION M Check entrols yokes imit Controls iv, a.( b.( c.' d..( e.( f. ( raulics /Pneumatics /Bolts/Keys ctural Integrity s/Wheels /Casters rings /Spindles /Axles Track/Rim Iron OT R a. a( ,( utomatc Sprinkler /Smoke Detector: b.( Ater Quality c.( ngy Cords d.( kanes e.(omments 4,c‘ _c,t O • vI`s RESULTS: DACS -03419 Rev. 3/11 white /Bureau Canary/ Owner or Manager Pink/Event - Gold /Inspector 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) # 1 379 3 6 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 complianc= with §616.242, F.S. The employee responsible for operating this ride has been trained in accordance with F.S. d the rnufacturers operating instructions or the operating fact sheets for this ride are available to the operator, last 14 dail in-+ :, tiorl'fe. - - completed and available u on reque Own_ /Ma :gerSignature Inspector's Sig ature PURSUAN ' TO Section 6 ), F.S., the above identified amusement ride does not meet the requirements of Section 616.242, F.S. and Chapter - ;, F.A.C. and shall not operate until it passes a subsequent inspection by the Department.' STOP OPERATION ORDER (DACS 03545, Rev. 12/09) # Owner/Manager Signature Inspector's Signature DACS -03419 Rev. 3/11 white /Bureau Canary/ Owner or Manager Pink/Event - Gold /Inspector 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. I have read this notice of rights: SIGNATURE OF OWNER DATE DACS -03419 Rev. ADAM H. PUTNAM 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) 921 -1530; Fax (850) 921 -1539 KIDDIE (1 N -KID REQUIREMENTS: (Check 1. RIDE STATUS a.( b.(r c.( d.( rmit urance mpliance /NDT Manuals 4. A CHMENTS n Attachments rrier/Tubs c ( traints d ( weeps DEFICIENCIES: Ride Owner Ride Name C. MFG Serial # USAID # Permit # E SUPER T Mt1 AM 41) t o ►.0 `°6'c j each requirement as it is accomplished or place 2. IN LLATION a. king b.( F ncing /Guarding c.( aces /Guys /Anchors d.( ns e. Electrical 5. OP RATION a M Check b.( pntrols c.( kes d.(imit Controls N e. — Unannounced Re- inspection - Permit Inspection/Red Tag History mpoiy,— Permanent Location hen Facin LOrtt►+ riC R. Q. A ritcksk,AA (N) if not applicable) 3. S�TURAL a.( raulics /Pneumatics b.(,, /Bolts /Keys 6.OT ructural Integrity es/Wheels/Casters sari ngs /Spindles /Axles rack/Rim Iron d.( e.( utomatic'Sprinkler /Srnbke Detector later Quality 1 ungy Cords r es omments 10 0' 1 4. J FCC 0 L RESULTS: Cu DACS- 03419 -Rev. 3/11 White /Bureau Canary/ Owner or Manager Pink/Event Gold /Inspector 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 a deficien 'es noted above. (if any) have been corrected. INSPECTION CERTFICATE (DACS 03550, Rev. 01/09) # 1 --7q4- !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. a the anufacturers operating instructions or the operating fact sheets for this ride are available to the operator, last 1 dail ecti - • ! s were completed and available upon request. Ow r/M ager'Signa Inspector's Signature PURSUA T.TO Sect • • 16,242(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. 12/09) # Owner /Manager Signature Inspector's Signature DACS- 03419 -Rev. 3/11 White /Bureau Canary/ Owner or Manager Pink/Event Gold /Inspector 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. I have read this notice of rights: SIGNATURE OF OWNER DATE DACS -03419 Rev. ADAM H. PUTNAM 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 sp4 o k Phone (850) 921 -1530; fax (850) 921 -1539 Ride Owner Ride Name MFG Serial # USAID # Permit # KIDDIE NON- KIDDIE REQUIREMENTS: (Check each requireme 1. RI STATUS a hermit b.Vripsurance c.( r mptiarice /NDT d.( d Manuals a.l b.(. c.( d.( CHMFNTS err Attachments ' r/Tubs straints Sweeps DEFICIENCIES: 0/1t o%) M r O A\ kAk nt as it is accomplished or place (N) if 2. IN ALLATION a. "rocking b.( cing /Guarding c.(4' ces/Guys/Anchors d.(rrs e.( lectrical 5. OP TION a. M Check b.(ntrols c.( es d.( imit Controls d — Unannounced Re- inspection - Permit Inspection /Red Tag History mpo - Permanent Location When Facing: L. r 0V/44{ R. not applicable) 3. ST- CTURAL draulics /Pneumatics s/Bolts /Keys Iructural Integrity es/Wheels/Casters earings /Spindles /Axles rack/Rim Iron 1 OT ER a.( utomatic Sprinkler/Smoke Del b.( ater Quality /, c.( ngy Cords d.( anes e.( omments 4 4 r RESULTS: DACS - 03419 Rev. 3/11 White /Bureau Canary/ Owner or Manager Pink/Event Gold /Inspector 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 31 i 33 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 complianc ith §616.242, F.S. The employee responsible for operating this ride has been trained in accordance with F.S. - d he n anufacturers operating instructions or the operating fact sheets for this ride are available to the operator, last 14•da in p-ctioi"iep• re completed and available upon re u it r" '%)tAk.44% S Owner /M- • - ignature `' Inspector's Signature PURSUA TO Section 61 . 2(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. 12/09) # Owner / Manager Signature Inspector's Signature DACS - 03419 Rev. 3/11 White /Bureau Canary/ Owner or Manager Pink/Event Gold /Inspector 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. have read this notice of rights: SIGNATURE OF OWNER DATE DACS -03419 Rev. ADAM H. PUTNAM 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) 921 -1530; Fax (850) 921 -1539 V.- ( 1 � Ride Owner D N 0 N``" ° C> i Lk I-- 4 ` ± F Ride Name ©' cape � 5 MFG 1 we r Serial# ra. I. USAID # Q 1 0 Permit # 3 chedul - Unannounced Re- inspection - Permit Inspection /Red Tag History T po` ry — Permanent Location When Facing: L. L"3j c • e KIDDIE Nil -IDIE SUPER REQUIREMENTS: (Check each requirement as it is accomplished or place (N) if not applicable) 1. R s., STATUS 2. INSTALLATION king a4(' rmit :( surance c.( mpliance /NDT d.( Manuals 4. A' : CHM NTS a. Attachments b.( rrier/Tubs c.( traints d.( Sweeps DEFICIENCIES :; ncing/Guarding ces /Guys /Anchors Is lectrical 3. ST a. b.( c. d.( e.( f. ( R. 0 c ,J �CTURAL traulics /Pneumatics �S /Bolts /Keys lretural Integrity 1ssNVheels /Casters arings /Spindles /Axles Track/Rim Iron 5.OPfrRATION 6. O TI+FER a.( tomatic,Sprinkler /Smoke Detector b.( titer Quality c.(' ngy Cords d.( nes e.( Comments Check ntrols rakes imit Controls. RESULTS -(C 1 4 C' 1 i 01 DACS -03419 Rev. 3/11 White /Bureau Canary/ Owner or Manager Pink/Event 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) # 1 3" / j q 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. a he manufacturers operating instructions or the operating fact sheets for this ride are available to the operator, last 1,4 dad in ectiii n re _• a - ere completed and available upon request. Own /M alter Siena = Inspector's Signature PURS A TO Se on 6 42(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. 12/09) # Owner/Manager Signature Inspector's Signature DACS -03419 Rev. 3/11 White /Bureau Canary/ Owner or Manager Pink/Event 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. I have read this notice of rights: SIGNATURE OF OWNER DATE DACS -03419 Rev. MI ADAM H. PUTNAM COMMISSIONER 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)921- 1530; Fax (850) 921 -1539 DATA: t 1 q Date f ..„ Vii- j .. Ride Owner Q / 4 '{ tALAJAy > Inspector Ride Name r G., w Event MFG Location Serial # USAID # Permit # NON - KIDDIE SUPER i■1l1 Sky-70 C R VSZcfrA4 11C1OuI 0 c1 c6ck edu - Unannounced Re- inspection - Permit Inspection /Red Tag History +. - Permanent Location When Facing: �. p q4,,%) R. vii p 4 •) mpora REQUIREMENTS: (Check each requirement as it is accomplished or place (N) if not applicable) 1. RIDF, STATUS 2. INS LLATION 3. ST UCTURAL a.( rmit a.( .eking a.( draulics /Pneumatics b.( urance b.( F cing /Guarding b. s /Bolts /Keys c.( pliance/NDT' c.( ces /Guys /Anchors c.( ctural Integrity d.( Manuals d.('ts d.( s/Wheels /Casters e.( lectrical e.( arings /Spindles /Axles f. { Track/Rim Iron HMENTS.. a ( _ n Attachments b.(. arrier/Tubs c.straints d.( Sweeps DEFICIENCIES: 5. OP TION a. M Check b.( ontrols c.( kes d.( ' imit Controls 6 a utomatic Sprinkler /Smoke Detector b. ater Quality c. pungy Cords d. anes e.( Comments RESULTS: s PACS -03419 Rev. 3/11 White /Bureau Canary/ Owner orlvlanager Pink/Event Gold /Inspector 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 1 ' 7 94.0 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. 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. - , • the:?<nanufacturers operating instructions or the operating fact sheets for this ride are available to the operator, last 14 dai, j ..ec ork re, • is were completed and available upon request. Ow r/ ager Si. natu Inspector's Signature PURSUA T 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. 12/09) # Owner /Manager Signature ' Inspector's Signature PACS -03419 Rev. 3/11 White /Bureau Canary/ Owner orlvlanager Pink/Event Gold /Inspector 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. I have read this notice of rights: SIGNATURE OF OWNER DATE DACS -03419 Rev. M. ADAM H. PUTNAM 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) 921 -1530; Fax (850) 921 -1539 Ride Owner Ride Name MFG Serial # USAID # Permit # KIDDIE N +t'+ IE SUPER REQUIREMENTS: (Check each requirement as it is accomplished or place (N) if not applicable) 1. RI STATUS 3. ST CTURAL MoOE'ri,J MttW4 { C4ST1 4 �►41 I c :3c1 ►�t3 - Unannounced Re- inspection — Permit Inspection /Red Tag History rtl — Permanent Location When Facing: ACAS *r • a:( b.( c.( d.( ermit s ranee ' ompliance/NDT Manuals 4 AT CHMkNTS en Attachments . rrier/Tubs c.( straints d.( weeps DEFICIENCIES: 2. INVALLATION a.cigitlifeckIng b.( ncing /Guarding c.( ces /Guys /Anchors d.(* e.( Iectrical 5. OP RATION a. M Check b.( ontrols c. ( akes d.( Limit Controls R. -10,- a. . raulics /Pneumatics b.( '' s /Bolts /Keys c.( S )uctural Integrity d . (es/W heels /Casters e.(10S rings /Spindles /Axles f. ( rack/Rim Iron 6. OT R a. tomatic Sprinkler /Smoke Detector b. ter Quality c.( ungy Cords ee.es .( omments RESULTS: DACS -03419 Rev. 3/11 White /Bureau Canary/ Owner or Manager Pink/Event Gold /Inspector 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) # / 3 79 [? ~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. - the manufacturers operating instructions or the operating fact sheets for this ride are available to the operator, last 14 dai , i' pectio°(e• •' s were completed and available upon request. rl , =nager Sig - Inspe tors Signature PURSU T TO Sect on . 16.242(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. 12/09) # Owner/Manager Signature Inspector's Signature DACS -03419 Rev. 3/11 White /Bureau Canary/ Owner or Manager Pink/Event Gold /Inspector 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. have read this notice of rights: SIGNATURE OF OWNER DATE DACS -03419 Rev. • ADAM H. PUTNAM COMMISSIONER DATA: �I Date l"' 4-110 `W # Ride Owner i 4 be' % Ml4WAyc Inspector 1 l $ Glr Ride Name Event Sr R 0 MFG Location Serial # USAID # Permit # KIDDIE Nit l i DIE SUPER is "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) 921 -1530; Fax (850) 921 -1539 9 6C1 - Unannounced Re- inspection — Permit Inspection /Red Tag History "'""^ — Permanent Location When Facing: L. 0 1Z. R liVtJ Svr otA -3 -3 REQUIREMENTS: (Check each requirement as it is accomplished or place (N) if not applicable) 1. Mg STATUS: a.( rmit b.( urance c.(mpliance /NDT ( Manuals 2. INSTALLATION ocking ncing /Guarding aces /Guys /Anchors s Iectrical 4.,A :. CHMENTS ( e - n Attachments ( rrier/Tubs c.(. traints d.( weeps 5. OP ' TION a.( : ' M Check b.( '•ntrols c.( es d.( Limit Controls 3. STRUCTURAL a.l� b.( c.(r d.(- e.( f. ( 6. OT a.(��!% b. c.e It d.( e.(1 jfdraulics /Pneumatics s /Bolts /Keys lactural Integrity jyes/Wheels /Casters aelrings/Spindles/Axles rack/Rim Iron utomatic Sprinkler /Smoke Detector later Quality ngy Cords banes omments DEFICIENCIES: RESULTS DACS -03419 Rev. 3/11 White/Bureau Canary/ Owner or Manager Pink/Event Gold /Inspector 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) # 1 2 7 q 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 t - Aanufacturers operating instructions or the operating fact sheets r this ride are available to the operator, last 14 daily in report completed and available upon requ S Owner a+ SSionetur Inspe tor's Signature PURSUANT • Section . 2(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. 12/09) Owner /Manager Signature Inspector's Signature DACS -03419 Rev. 3/11 White/Bureau Canary/ Owner or Manager Pink/Event Gold /Inspector 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. have read this notice of rights: SIGNATURE OF OWNER DATE DACS -03419 Rev, ADAM H. PUTNAM 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) 921 -1530; Fax (850) 921 -1539 "' 1 a,.., Ride Owner S r► Ride Name MFG x V a t *4.S Serial # q 53/ 3 4- USAID # 115 02— Permit # A-% lg j s t4 Q r" or KIDDIE NON-KIDDIE REQUIREMENTS: (Check each 1. RI 'S ATUS a.( rmit b.( jpisurance c.(41 mpliance /NDT d.(. Manuals 4, TT CH ENTS .( n Attachments :b.( rriet Tubs c.f straints d.(eeps �r DEFICIENCIE chedul— Unannounced Re-inspection — Permit Inspection /Red Tag History .4mpora Permanent Location Wf��n Facing: L. t t t (.e R. QQ regUirement`as it is accomplished or place (N) if not applicable) 2. IN ALLATION a. : • eking b.( F ncing /Guarding c.( races /Guys /Anchors d. ns Electrical :( 5. OP TION a. M Check b.( ntrols c.( es d.( imit Controls 4Y 3. ST5UCTURAL a. draulics /Pneumatics b.(. /Bolts /Keys c.(dor uctural lntegrity d.( ' esNVheels /Casters e.( Ejearings /Spindles /Axles f. ( rack/Rim Iron 6.OT ER a.( ' utomatic rink(er /Smoke Detector b.( 9. ater Quality c.( : ungy Cords d.( anes e.( omments Ma RESULTS: DACS -03419 Rev. 3/11 White /Bureau Canary/ Owner or Manager Pink/Event Gold /Inspector 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) # % '3"i ci i 9 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 co fiance ith §616.242, F.S. The employee responsible for operating this ride has been trained in accordance with S. an , nufacturers operating instructions or the operating fact sheets this ride are available to the operator, last 14 daily s • • c 'r ' re • . - -.. ere completed and available upo J Own /Ma• :_•er Signa Inspector's Signature PURSU TO Se • . .242(7), F.S., the above identified amusement ride does not meet the requirements of Section 616242, 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. 12/09) Owner /Manager Signature ,�,; Inspector's Signature DACS -03419 Rev. 3/11 White /Bureau Canary/ Owner or Manager Pink/Event Gold /Inspector 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. I have read this notice of rights: SIGNATURE OF OWNER DATE DACS -03419 Rev. ADAM H. PUTNAM COMMISSIONER Florida Department of Agric(lture 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) 921 -1530; Fax (850) 921 -1539 DATA: tt Date ., V "" : __*_ ? Ride Owner M o tt e rsa M I AA / S Unannounced Inspector t P5 Ride Name e\r 1 i 1 Re- inspection — Permit Event ST l C MFG C 1 Ar L., Inspection /Red Tag History Location Serial # J04 "S 'L.'r T'4.Nita io4 — Permanent USAID # 0 I — 0 --31, Location Men Facing: Permit # i.-\\ - .. L. ;f SI 1 t R. KIDDIE F IE SUPER REQUIREMENTS: (Check each requirement as it is accomplished or place (N) if not applicable) 1. RI STATUS 2. IN§TALLATION 3. ST 4lCTURAL a rmit a.(4 ticking a. raulics /Pneumatics tl ( urance b. cing /Guarding b.( /Bolts /Keys c „(;4mpliance /NDi ` c.( ces /Guys /Anchors c.(,ructural Integrity anuals d.( • s d.( • es/Wheels /Casters e.( . Electrical e.( arings /Spindles /Axles f. ( rack/Rim Iron . CHMENTS 5. OP - TION 6 O a.( en Attachments a. r PM Check a.( utomatic Sprinkler /Smoke Detector b: arrier/Tubs b.( IP . ntrols b( ater Quality c.( estraints - c.( ;rakes c. ungy Cords d.( Sweeps d.( imit Controls d. apes e.( Comments DEFICIENCIES: 4'f MtSS1"J 4'o'4 i f ( .rot .. ., , RESULTS: { /- 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 les noted above (if any) have been corrected. INSPECTION CERTFICATE (DACS 03550, Rev. 01109) #' '2 '7 5 3 U 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 cornpilance: with §616.242, F.S. The employee responsible for, operating this ride has been trained in accordance with F.S. and t e manufacturers operating instructions or the operating fact sheets for this ride are available to the operator, last 14 daily ct n r • • ere completed and available upon re ues fix A • 'er/ i ager Signa Inspector's Signaturee PURS ° NT TO Sect . 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, E.A.C. and shall not operate until it passes a subsequent inspection by the Department. STOP OPERATION ORDER (DACS03545, Rev. 12/09) # Owner /Manager Signature Inspector's Signature DACS -03419 Rev. 3/11 white /Bureau Canary /.Owner or Manager Pink/Event Gold /Inspector 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. I have read this notice of rights: SIGNATURE OF OWNER DATE DACS -03419 Rev. ADAM H. PUTNAM 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) 921-1530; Fax (850) 921 -1539 Ride Owner Ride Name MFG Serial # USAID # Permit # L\ O `` IE, SUPER KIDDIE .. N.' REQUIREMENTS: (Check 'I. RI STATUS a.( rmit b.( ipsurance c.( pliance /NDT d.( annals 4. 4.T CI MENTS a.( n Attachments b.( rrier/Tubs c.( straints d.( Sweeps DEFICIENCIES: S — Unannounced Re- inspection - Permit Inspection /Red Tag History — Permanent Location When Facing: L.Q vil R. Fslw'h v mpora each requirement as it is accomplished or. place (N) if not applicable) 2. IN a.( ocking b.( ncing /Guarding c.( paces/Guys/Anchors d.( RS e.( lectrical ALLATION 3. ST�U a.( b.(, c.(r d.( e.( f. ( 5. OP TION a.( M Check b.( ontrols c.( ).rakes d.( ) Limit Controls 1i e,.tkt4 c 1 c.‘,)C4 b N ttIN 6.OT a•(,•3i b.( CTURAL ydraulics /Pneumatics ins /Bolts /Keys uctural Integrity esNVheels /Casters wrings /Spindles /Axles rack/Rim Iron ER .itomatic Sprinkler /Smoke Detector ter Quality c.( iingy Cords d.( nes e.( omments RESULTS: DACS- 03419 Rev, 3/11 White /Bur u Canary/ Owner or Manager Pink/Event Gold /Inspector 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) # 1 319 1 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. an. ": manufacturers operating instructions or the operating fact sheets for this ride are available to the operator, last 14 daily ' tii1 repo completed and available upon request. O /Ma °oer ignature Inspector's Signature PURSUA TO Section 61 7), F.S., the above identified amusement ride does not meet the requirements of Section 616.242; .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. 12/09) # Owner/Manager Sign' - Inspector's Signature DACS- 03419 Rev, 3/11 White /Bur u Canary/ Owner or Manager Pink/Event Gold /Inspector 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. I have read this notice of rights: SIGNATURE OF OWNER DATE DACS -03419 Rev. ADAM H. PUTNAM COMMISSIONER. DATA: Florida Department of Agriculture and Consumer Services Bureau of Fair Rides Inspection AMUSEMENT RIDE INSPECTION REPORT Section 616.242(4), Florida Statutes RuIe 5F-8.0012, Florida Administrative Code Date �" +}�►,.., Inspector Event Location C tot Phone (850) 921 -1530; Fax (850) 921 -1539 Ride Owner Ride Name MFG Serial # USAID # Permit # NON - KIDDIE SUPER REQUIREMENTS: (Check each requirement as it is accomplished or place (N) if not applicable) /44Jt AAAW ?. t tA -r *'c \ czcacioQ 44 3-3- — Unannounced Re- inspection — Permit Inspection /Red Tag History T por • - Permanent Location When Facing: L. —101 R. -30 1. RI ' <- STATU a.( b.( c.( d.( 1'. rmit surance ��• mpliance /NDT Manuals 4..ATT CHMENTS a.(. n Attachments b.( rrier/Tubs c.( straints d.( Sweeps DEFICIENCIES: 2. IN ALLATION a.( - ocking b. racing /Guarding c.( ces/Guys/Anchors d.( 41S e.( lectrical 5. OP TION a. ' ' M Check b.( ntrols c.( kes d.( Limit Controls 3. STJEUCTURAL a.( draulics /Pneumatics b.( ns /Bolts /Keys c.(1 ru ctu ra l Integrity d.( es/Wheels /Casters e. (wrings /Spindles /Axles f. ( Track/Rim Iron 6.'T R a. tomatic Sprinkler /Smoke Detector b ater Quality c. ungy Cords d. rr anes e ( omments RESULTS: C� DACS�03419 Rev. 3/11 White /Bureau Canary/ Owner or Manager Pink/Event Gold /Inspector 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 deficie ties noted above (if any) have been corrected. INSPECTION CERTFICATE (DACS 03550, Rev. 01/09) # 1 37ttt4 V 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. a the manufacturers operating instructions or the operating fact sheets for this ride are available to the operator, last 14 dail .p -. tion reports were completed and available upon request. • / 'ner Signature Inspector's Signature, PURSU T TO Section-6 2(7), F.S:, the above identified amusement ride does not meet the requirements of Section 616.242, i.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. 12/09) # Owner /Manager Signature inspector's Si• ature DACS�03419 Rev. 3/11 White /Bureau Canary/ Owner or Manager Pink/Event Gold /Inspector 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. I have read this notice of rights: SIGNATURE OF OWNER DATE DACS -03419 Rev. ADAM H. PUTNNAM. 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) 921 -1530; Fax (850) 921 -1539 j Ride Owner O Ride Name MFG Serial # USAID # Permit # v0er'&) lift4�A/ )y > d— Unannounced i R 0 v� iSt � Re- inspection — Permit ( CA c Inspection /Red Tag History % J LMoi V40 T — Permanent c:i Location When Facing: t'- C,146 L. txj? j R. Zo\ KIDDIE NO-ICI IE SUPER REQUIREMENTS: {Check each requirement as it is accomplished or place (N) if not applicable) 1. RI STATUS a. P f, b.( urance c.( mpliance /NDT d.( anuals 4 AT CHM NTS :( - n Attachments 'b.( , rrier/Tubs c.( traints d.( Sweeps DEFICIENCIES: �►A 2. IN ;IFALLATION a.(, )ocking b.( ncing /Guarding c.( aces /Guys /Anchors d.(. igas e.( Electrical 5. OP TION a.( M Check b.( ntrols c.( kes d.( Limit Controls 3. ST-UCTURAL draulics /Pneumatics s /Bolts /Keys uctural Integrity es/Wheels /Casters rings /Spindles /Axles Track/Rim Iron T ER utomatic Sprinkler /Smoke Detector ater Quality ungy Cords CC�aanes Comments t� koccoAS o . ' 14m `t 009(t. Icc("cie- Ot, RESULTS: DACS - 03419 Rev. 3/11 White /Bureau Canary/ Owner or Manager Pink/Event Gold /Inspecteir 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.G. and the deficiencies noted above (if any) have been corrected. INSPECTION CERTFICATE (DACS 03550, Rev. 01/09) # f44`- 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. - " +' he manufacturers operating instructions or the operating fact sheets for this ride are available to the operator; last 14 da > i . » - on repo ere completed and available upon request. .•° O er `anager Stgna .� Inspector's Signature PURS ° NT TO Sect .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. 12/09) # Owner /Manager Signature Inspector's Signature DACS - 03419 Rev. 3/11 White /Bureau Canary/ Owner or Manager Pink/Event Gold /Inspecteir 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. I have read this notice of rights: SIGNATURE OF OWNER DATE DACS -03419 Rev. ADAM H. PUTNAM COMMISSIONER DATA: Date Inspector Event Loom Florida Department of AgricIture 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) 921 -1530; Fax (850) 921 -1539 Ride Owner / "1Obe1`14b"'I 14 A Ride Name MFG Serial # USAID # Permit # KIDDIE - IE SUPER REQUIREMENTS: (Check each requirement as it is accomplished or place (N) if not applicable) 1. R16a1Ei'STATU$ 2. INSL4LLATION 3. ST- CTURA 141'4 Rol ! C' ,etln — Unannounced Re-inspection — Permit Inspection /Red Tag History Permanent Location When Facing: L. J T �i'L R. " `W c + or a:( t.t. .( rmit surance mpliance/NDT anuals ►° CHMENTS n Attachments (; rrier./Tubs (` straints . (4Sweeps DEFICIENCIES: # e„�a ticking encing /Guarding Daces /Guys /Anchors inns lectrical 5. OP C PM Check a b.ontrols c. es d.( imit Controls 'akc oC i.1Sk o,$) +raulics /Pneumatics } /Bolts /Keys S turallntegrity heels /Casters arings /Spindles/Axles Track/Rim Iron 6 «T - ER a. utomatic Sprinkler /Smoke Detector b.('1' /ater Quality ungy Cord ;►> nes omments c.N d.( e.( lk r RESULTS: DACS-03419 Rev. 3/11 White /Bureau Canaly/ Owner or Manager Pink/E,vent Gold /Inspector Inspection PURSUANT TO Section 616.242(7), F.$., 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) # / 37 fl 37' 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 th- anufacturers operating instructions or the operating fact sheets for this ride are available to the operator, last 14 daily in- , -.• • , eports w mpleted and available upon request. Owner an- - Signature Inspector's Signature PURSUANT 0 Section 616. , 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. 12/09) Owner /Manager Signature Inspector's Signature DACS-03419 Rev. 3/11 White /Bureau Canaly/ Owner or Manager Pink/E,vent Gold /Inspector 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. I have read this notice of rights: SIGNATURE OF OWNER DATE DACS -03419 Rev. 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) 921 - 1530; Fax (850) 921 -1539 Ride Owner Ride Name MFG Serial # USAID # Permit # — Unannounced Re- inspection - Permit Inspection /Red Tag History — Permanent Location When Facing: L.0 rChl R. Mto KIDDIE NON-KIDDIE REQUIREMENTS: (Check each requirement as it is accomplished or place (N) if not applicable) 1. RI' STATUS 2. INS LLATION 3. ST; CTURA tacking cing /Guarding races /Guys /Anchors Ifs lectrical 4, AT CHMENTS a.(.+J'n Attachments b.( rrierFrubs c.( taints d.(, weeps .;.RATION FPM Check ntrols imit Controls draulics /Pneumatics s /Bolts /Keys uctural Integrity es/WheelS /Casters Wirings /Spindles /Axles Track/Rim Iron •T, R tomatic Sprinkler /Smoke Detector i ater Quality gy Cords �► anes Comments DEFICIENCIES: It. NI :h t ` S RESULTS: DACS -03419 Rev. 3/11 White/Bureau Canary/ Owner or Manager Pink/Event Gold /Inspector Inspeci 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 2"-j .34i 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 daily i 1 - • tibh reports were completed and available upon reque / X Sdfr-. • ; her anager Signs * Inspector's Signature PURSklANT TO Section • : (7), F. ., the above identified amusement ride does not meet the requirements of Section 616.242, F.S. and Chapter 5F-8, FA.C. and shall not operate until it passes a subsequent inspection by the Department. STOP OPERATION,ORDER (DACS 03545, Rev. 12/09) # Owner /Manager Signature ' Inspector's Signature DACS -03419 Rev. 3/11 White/Bureau Canary/ Owner or Manager Pink/Event Gold /Inspector Inspeci 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 DACS -03419 Rev. ADAM H. PUTNNAM COMMISSIONER DATA: Date Inspector Event Location Florida Department of Agriculture and Consumer Services Bureau of Fair Rides Inspection AMUSEMENT RIDEINSPECTION REPORT Section 616.242(4), Florida Statutes Rule 5F- 8.0012, Florida Administrative Code Phone (850) 921 -1530; Fax (850) 921 -1539 44ASO o %1 Ride Owner Ride. Name MFG Serial # USAID # Permit # NON- KIDDIE SUPER REQUIREMENTS: (Check each requirement as it is accomplished or place (N) if not applicable) M rA) N11 /r , 7 -C1 Unannounced Re- inspection — Permit Inspection /Red Tag History .�- - Permanent Location When Facing: C w.h R. j.A�,J edule 1. RIDE STATUS 2. INSTALLATION b. ermit b. urance c.( mpliance /NDT d.( Manuals a.( b.( CHMENTS n Attachments rrier/Tubs estrairits Sweeps DEFICIENCI a.(, b.( c.( d.( e.( flocking 9ncing /Guarding races /Guys /Anchors ►9ns Iectrical 5. OP TION a )PM Check b. YerSontrols c. Oakes d.( Limit Controls u f NIA \ 3.ST-UCTURA_ A. draulics /Pneumatics b. s /Bolts /Keys c.( ructural integrity d. s/Wheels /Casters e.( )earings /Spindles /Axles f. ( Track/Rim Iron 6 TER a �ttatomatic Sprinkler /Smoke Detector b ( ' Ater Quality c.( ngy Cords d.(�nes e.( omments RESULTS: DACS- 03419 Rev. 3/11 White /Bureau Canary/ Owner or Manager Pink/Event Gold /Inspector Inspection PURSUANTI O 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) # acknowledge tide, 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 . anufacturers operating instructions or the operating fact sheets for this ride are available to the operator, last 14 daily i ,. - . lull reports w - - completed and available upon request. "' O' - IM. - • -r Signature l spector's Signature PURSU TO Section a' . 42(7), F.S., the above identified amusement ride does not meet the requirements of Section 616. 242, F,S. ant(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. 12/09) # Owner /Mansur Signature Inspector's Signature DACS- 03419 Rev. 3/11 White /Bureau Canary/ Owner or Manager Pink/Event Gold /Inspector 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. I have read this notice of rights: SIGNATURE OF OWNER DATE DACS-03419 Rev. Miami Shores Village Building Department 10050 N.E.2nd Avenue, Miami Shores, Florida 33138 Tel: (305) 7952204 Fax: (305) 756.8972 INSPECTION'S PHONE NUMBER: (305) 762.4949 BUILDING Permit No. WC) PERMIT APPLICATION Master Permit No. FBC 20 Permit Type: MECHANICAL OWNER: Name (Fee Simple Titleholder): Archdiocese of . M j ami Phone#: (305 -) 727 -f 74'I Address: --9401 BtScay-ne— Blvd City: Miami Shores State: FL Tap:33138 Tenant/Lessee Name' $J _ RDsp .nf - T.i ma Catholic Church pho ( 3 0 5 ) 758 -0539 Email: JOB ADDRESS: 418 NE 105th Street City: Miami Shores County: Miami Dade Zip: Folio/Pa:rel#: Is the Building Historically Designated: Yes NO Flood Zone: CONTRACTOR: Company Name: _Modern Midways, Inc. Phones' Address: 10420 SW 1 1 5 S treet City: Miami State: FL Zip: 33176 Qualifier Name: Brian ,orrissey Phone#: ( 7 8 6 ) SRFi -9568 State Certification or Registration #: Certificate of Competency #: Contact Phone#: (305)234-7776 Email Address: 10420 SW 115 Street. DESIGNER Architect/Engineer: Phone#: Value of Work for this Permit: $ 4 0 0 . Square/Linear Footage of Work: Type of Work: DAddress DAlteration Description of Work: ONew ORepair/Replace ODemolition Submittal Fee $ Permit Fee $ 1--) V/ CCF $ CO /CC $ Scanning Fee $ Radon Fee $ DBPR $ Bond $ Notary $ Training/Education Fee $ Technology Fee $ Double Fee $ Structural Review $ TOTAL FEE NOW DUE $'D 19 • (U (/ 2012 Bonding Company's Name (if applicable) Bonding Company's Address City State Mortgage Lender's Name (if applicable) Mortgage Lender's Address City Staff T,hp 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 Ls subject to attachment. Also a cert jed copy of the recorded notice of commencement nuts* be posted at thejob site for the first inspection which occurs seven (7) days after the building permit is issued In the absence of such posted notice, the liupedlon will not be fee will be charged t/ Owner or Agent The foregoing instrument was acknowl day of (Jd44r bt,20 Ii by who is before me this )1-T41 itp idamf�(% RRiSSEY = - i id Imo,' : = EXPIRES: December 27, 2013 Y Bonded Thru Notary Public Under/niters NOTARY Print: 4 tZL tip Tit ra)ti&Si1 My Commission Expires: I "-J17 /1.1 Signature The foregoing instrument was acknowledged before me this c' day of / ice , 20 by 17/14,1--A/ who is personally known to me or who has produced as identification and who did take an oath. NOTARY PUB Sign: 'l My Commission Expires: Stcuctmal Review (Revised 07n0107)(Revised 0910 )(Revi sed 3/15109) Clerk MIAMI -DADE COUNTY TAX COLLECTOR 140 W. Flagler Street Miami, Florida 33130 Please keep your receipt for future reference. Thank you and have a nice day. 1/11/2012 1300/223/OO1TRAA 0025 -0001 Last Seq. #:0001 WI LBT #:00 595330 -3 Local Business Tax $352.50 CK $352.50 CHANGE $0.00 MIAMI -DADE COUNTY TAX COLLECTOR LOCAL BUSINESS TAX SECTION 140 W. Flagler St. - 1st Floor Miami, Florida 33130 TEMPORARY RECEIPT 2011 -2012 LOCAL BUSINESS TAX Local Business Tax #:00595330 -3 State/CC #:NA Issued to: MODERN MIDWAYS Type of. Business: CARNIVAL - SPONSORED THIS RECEIPT IS ISSUED AS EVIDENCE OF PAYMENT FOR YOUR LOCAL BUSINESS TAX OR PERMIT. YOUR OFFICIAL RECEIPT WILL BE MAILED TO YOU WITHIN 10 DAYS FROM THE VALIDATION DATE ON THIS RECEIPT. Payment Received as Certified Above Miami -Dade County Tax Collector '4� °® CERTIFICATE OF LIABILITY INSURANCE DATE (MWDDIYYYY) 12/07/2011 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POUCIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement A statement on this certificate does not confer rights to the certificate holder In lieu of such endorsement(s). PRODUCER 1 -425- 454 -3386 Arthur J. Gallagher Risk Management Services, Inc. P.O. Box 367 Bellevue, WA 98009 -0367 NAME Joanne Manion PHONE FAX um No Em): 425 -454 -3386 (Am No): 425- 451 -3716 ADDRESS: INSURER(8) AFFORDING COVERAGE NAIC0 INSURERA: T.8.E. Insurance Company LIABILITY COMMERCIAL GENERAL LUIBILITY INSURED Briggs Transport, Inc. Modern Midways, Inc. 22901 Sherman Road Steger, IL 60475 INSURER B : CPP0100902 -01 INSURER C: 04/03/12 INSURERD: $ 1,000,000 INSURERS: $ 50, 000 INSURER F : $ E 24362240 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POUCY 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 LTR TYPE OF INSURANCE IINNSR WVD POLICY NUMBER (MMIDDIYYY1f) (MMIDDIYYYY) wars A GENERAL X LIABILITY COMMERCIAL GENERAL LUIBILITY CPP0100902 -01 04/03/11 04/03/12 EACH OCCURRENCE $ 1,000,000 RENTED PDAMAGE ISES (Ea occurrence) $ 50, 000 MED EXP (My one person) $ CLAIMS-MADE g OCCUR PERSONAL &ADVINJURY $ 1,000,000 GENERALAGGREGATE $ 2,000,000 PRODUCTS- COMPIOP AGO $ 1,000,000 GENT_ AGGREGATE LIMIT APPUES PER -' 1POLICYI Iimoi —1 LOC $ A AUTOMOBIELIABRRY — S ANY AUTO OWNED AUTOS HIRED AUTOS g 8 SCHEDULED AUTOS NON- AUTOS CPP0100902 -01 04/03/11 04/03/12 CO N NGLEUMIT 1,000,000 BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE (Per accident) $ $ A _UMBRELLALIAB EXCESSLIAB OCCUR CLAIMS -MADE ELP0010210 -01 04/03/11 04/03/12 EACH OCCURRENCE $ 4,000,000 AGGREGATE $ 4,000,000 $ DED RETENTION $ 0 WORKERS COMPENSATION AND EMPLOYERS' UASIUTY ANY PROPRIETOR/PARTNER/DECUIIVE Y / N OFFICERMIEMBEREXCLUDED? (Mandatory In NH) DESSCRId POTION OOF OPERATIONS below N /A I TORY STATU- I I T E.L EACH ACCIDENT $ E.L DISEASE- EA EMPLOYEE $ E.L DISEASE - POUCY LIMIT $ DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, If more apace Is required) The Archdiocese of Miami: Archbishop Thomas Wenski) St. Rose of Lima Catholic Church and 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 - policy form CG133C 07/95. Event Dates: January 26 - 29, 2012 Village of Miami Shores c/o Building Dept. 10050 NE 2nd Avenue Miami Shores, FL 33138 1 MIA SHOULD ANY OF THE ABOVE DESCRIBED POUCIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE 14 7 ACORD 25 (2010105) jomanion 24362240 ®1888 -2010 ACORD CORPORATION. All rights resery ed. The ACORD name and logo are registered marks of ACORD PRODUCER 203 - 931 -7095 Specialty Insurance, LTD -Tom Plouffe P.O. Box 16901 West Haven, CT 06516 DATE (MM/DD/YY) 10 -25-11 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. COMPANIES AFFORDING COVERAGE COMPANY TRAVELERS PROPERTY & CASUALTY CO OF AMERIC A INSURED MODERN MIDWAYS, INC. 879 JOLIET STREET DYER, IN 46377 COVERAGES COMPANY B COMPANY C COMPANY D 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 CONDrrION 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 POUCIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. Co LTR TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE DATE (MMIDDIYY) POLICY EXPIRATION DATE (MWDD/YY) LIMITS GENERAL LIABILITY COMMERCIAL GENERAL LIABILITY CLAIMS MADE OCCUR OWNER'S & CONTRACTOR'S PROT GENERAL AGGREGATE $ PRODUCTS - COMP/OP AGG PERSONAL & ADV INJURY EACH OCCURRENCE $ FIRE DAMAGE (Any one tire) $ MED EXP (Any one person) $ AUTOMOBILE LIABIUTY ANY AUTO ALL OWNED AUTOS SCHEDULED AUTOS HIRED AUTOS NON -OWNED AUTOS COMBINED SINGLE LIMIT $ BODILY INJURY (Pr per) $ BODILY INJURY (Per occident) PROPERTY DAMAGE $ GARAGE UABU TIY ANY AUTO AUTO ONLY - EA ACCIDENT OTHER THAN AUTO ONLY: EACH ACCIDENT AGGREGATE EXCESS LIABILITY UMBRELLA FORM OTHER THAN UMBRELLA FORM EACH OCCURRENCE AGGREGATE A WORKERS COMPENSATION AND EMPLOYERS' LIABIUTY THE PROPRIETOR/ PARTNERS/EXECUTIVE OFFICERS ARE OTHER nINCL JI EXCL 13- 1080411298- 9614021 N 10/25/12 X WC LIMITS I ER EL EACH ACCIDENT $ 1,000,000 EL DISEASE - POLICY UMR $ 1,000,000 EL DISEASE - EA EMPLOYEE $ 1,000,000 DESCRIPTION OF OPERATIONS ILOCATIONSIVEHICLES /SPECULL ITEMS Archdiocese of Miami, Archbishop Thomas Wenski, St. Rose of Lima Catholic Church, and 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. CERTIFICATE HOLDE Village of Miami Shores do Building Dept. 10050 NE 2nd Avenue Miami Shores, FL 33138 SHOULD ANY OF THE ABOVE DESCRIBED POUCIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING COMPANY 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 COMPANY, ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE Thomas A. Plouffe ACORD S-S (1 Q ACORD CORPORATION 1986:; NAME OF ORGANIZATION: ADDRESS: CONTACT PERSON: /� EVENT /GENERAL ACTIVITIES: l "Q��' VII Cl DATE: ' /13.. SPECIAL EVENT APPLICATION hst 1, P0NSA iu _Sit \ A .. PHONE: 16 C-10 ' t MN ► : PHONE: 4c [� b t- ))61 EVENT LOCATION: qic ,� 1K41 (q" 1 "li J r\( qLe , 71711 Zit SET-UP START END DAY 1"6 G C qwidol CLEAN -UP 401 DATE g (11 , 1' S 41 -2/0/ PLEASE ANSWER THE FOLLOWING IF APPLICABLE: 1) Will alcohglic beverages served? If yes, what type? i 8e OkIn(� 1 ht FROM (am /pm) X100 u, IdO1 100 TO (am /pm) -4.40 _PM 110 0 �M 1k0PM 10ObPM 2) Will rides, bounce houses, or games of chance be offered? If yes, please provide list including owners name /address, a copy of the insurance certificate and licenses. 3) Will a tent be erected? If yes, attach a separate list with contractor's name /address, insurance certificate and licenses. O M' OWIA Will you be charging admission? 4) 5) 6) Will amplified music be played? Are street closures .planned? If yes, which streets and at what times? f- 7) Will security be provided and by whom? 8) Will Village staff, equipment or services be required? If so, please elaborate. Ind. MmOal'iep, are h'i Additional comments pertinent to the event / special conditions It is understood by the applicant that this application is subject to review and approval by Village staff and may • be revoked at any time for non - compliance with rules, local ordinances, state statutes or if the event endangers the health, safety, or welfare of the public. The Village reserves the right to cancel the event should any conflicts arise with scheduling, and will give reasonable notice to the applicant for the purpose of rescheduling. As applicant, I agree to abide by all conditions and requirements of the Village and that I will indemnify and hold harmless the Village, its employees, and agents harmless from any and all legal, equitable, tort, contract, or any other claims, suits, actions, judgements, attorney's fees, court costs, and any expenses whatsoever arising from this event and the use of the property. Applicant agrees to obtain, pay for and keep in force, a general liability insurance binder with policy limits of $1,000,000 for any one accident/incident and any one person. In addition, a bond of $ is required for assurance of clean -up and protectio a+ ainst property damage. 1' f �,`l ► `'� I ► k At Sign uve' c.0�Vkl \JOt E4 xe Title 016- Village Attorney Police Chief ✓ Public Works Building AI 16 Planning & Zoning Ohl Finance V Other DISAPPROVED BY VILLAGE MANAGER Sec ovuttel fo be ccxj�rdtic+ed �' �utitt 1'6 <<c e coAtrd scoil falls Q 3OS- -Ic15 -akto addl owl seerui ces are requ aecQ Emu& Polo t.c. (x, irks. Exvre ° a.(r �Ik &-e t (� cho.k s a�tYe moue &o( ckiNP rot YN1, are (Wiled l Ot vAWel tAkctIAVer. uev k; ca ka ham loco. p fokk fed APPROVED BY VILLAGE MANAGER