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MC-13-89Inspection Worksheet Miami Shores Village 10050 N.E. 2nd Avenue Miami Shores, FL Phone: (305)795 -2204 Fax: (305)756 -8972 Inspection Number: INSP - 184276 Permit Number: MC- 1 -13 -89 Scheduled Inspection Date: January 24, 2013 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 Phone: (305)234 -7776 Building Department Comments TEMPORARY CHURCH CARNIVAL Infractio Passed Comments INSPECTOR COMMENTS False Q--e 2- 3 Passed Failed Correction Needed Re- Inspection Fee No Additional Inspections can be scheduled until re- inspection fee is paid. Inspector Comments PLEASE PICK UP REPORT OF THE STATE INSPECTION. January 23, 2013 For Inspections please call: (305)762 -4949 Page 15 of 26 ADAM H. PUTNAM COMMISSIONER Florida Department of Agriculture and bonsumer Services Division of Consumer Services /Bureau of Fair Rides Inspection AMUSEMENT RIDE INSPECTION REPORT Section 616242(4), Florida Statutes Rule 5F- 8.0012, Florida Administrative Code Phone: 1,800 - 435 -7352; Fax: (850) 921 -1539 FairRides@FreshFromFlorida.com DATA:., Date / — 9 Q 3 Inspector e 0 '1- Event g.° Location Ride Owner Ride Name MFG Serial # USAID # Permit # KIDDIE NON -DIE SUPER jobetr r6[414 d =gyp ti� tgie `-I Li cuti-1 ch#jod - Unannounced Re- inspection - Permit Inspection /Red Tag History - Permanent Location When Facing: L. tr. REQUIREMENTS: (Check each requirement as it is accomplished or place (N) if not applicable) 1. RIDE STATUS a.( hermit b.()frisurance c. ( .ompliance /NDT d.(wf Manuals 4. ATTACHMENTS a.( Oen Attachments b.( tarrier/Tubs c.( straints d.( Sweeps 2. INSTALLATION a.(Jecking b.( Fencing /Guarding c.( 0-aces/Guys/Anchors d.(igns e.( Electrical 5. OPERATION a.(R M Check b.(. �ontrols c.(tBrakes d.(,imit Controls R. 3, STRUCTURAL a.(lydraulics /Pneumatics b.( G s /Bolts /Keys c.( tructural Integrity d.( Tires/Wheels /Casters e.(arings /Spindles /Axles f. ( Track/Rim Iron 6. OTHER a.((-,4 °Aetomatic Sprinkler /Smoke Detector b.( <01 /ter Quality c.(ngy Cords d.(49anes e.(4Cornments DEFICIENCIES: GAY, a dtd a J-69 ;e6;er-- 17-7) c RESULTS: DACS -03419 Rev. 12/09 White /Bureau Canary/ Owner or Manager Inspection PURSUANT TO Section 616242(7), F.S., AN INSPECTION CERTIFICATE IS ISSUED, when box is checked. The above identified amusement ride meets the requirements of Section 616242, F.S. and Chapter 5F -8, F.A.C. and the deficiencies noted above (if any) have been corrected. INSPECTION CERTFICATE (DACS 03550, Rev. 01/09) # S 1 acknowledge ride is §616242(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, FS. The employee responsible for operating this ride has been trained in accordance with F.S. and the manufacturers operating instructions or the operating fact she,. - : = -this ride are available to the operator, las daily inspection reports were completed and available upoe . — -- - -- Owner /Manager SSignature Insp,'ctor's Signatu PURSUANT TO Section 616242(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. 12/09 White /Bureau Canary/ Owner or Manager 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. 12/09 ADAM H.iPUTNAM COMMISSIONER DATA: Date Inspector Florida Department of Agriculture and Consumer Service Division of Consumer Services /Bureau of Fair Rides Inspection AMUSEMENT RIDE INSPECTION REPORT Section 616242(4), Florida Statutes Rule 5F- 8.0012, Florida Administrative Code Phone: 1- 800 -435 -7352; Fax: (850) 921 -1539 FairRides @FreshFromFlorida.com Ride Owner Ride Name Event „ MFG Location Serial # USAID # Permit # KIDDIE NON - KIDDIE SUPER REQUIREMENTS: (Check each requirement as it is accomplished or place (N) if not applicable) e SY V (AA as 4 mte�d = Unannounced Re- inspection - Permit Inspection /Red Tag History ^� Tern ra - Permanent Location When Facing: L— L.-lokarr R. 5 o cs & v_ 1. RIDE STATUS a.( .'P it b.( rylbsurance c.( pliance /NDT d.( Manuals 4. ATT CHMENTS a:( n Attachments b.(c4arrier/Tubs c;( straints d.(c weeps DEFICIENCIES: 'r) 2. INS,'TALLATION a.( (Blocking b. (,Fencing /Guarding! c.( B„aces /Guys /Anchors d.(fSgns e.(3lectrical 5. OPERATION a.(RPM Check b.(Uontrols c.(rakes d.( imit Controls 3. STRUCTURAL, a.( ydraulics/Pneumatics b.( /Bolts /Keys c.( S ructural Integrity d.( tres/W heels /Casters e.( ari ngs /Spindles /Axles f. ( rack/Rim Iron 6. OTHER utomatic Sprinkler /Smoke Detector b. ater Quality c.( ngy Cords d.( Cnes e.(6 omments 0 o__\ kik_ iutot e 4c-o_ cvos,c Q C- V i RESULTS: DACS -03419 Rev. 12/09 White /Bureau Canary/ Owner or Manager Pink/Event 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 616242, F.S. and Chapter5F -8, F.A.C. and the deficiencies noted above (if any) have been corrected. INSPECTION CERTFICATE (DACS 03550, Rev. 01/09) # % °. F -g A-5.1 I acknowledge ride is §616242(16), and the receipt of this inspection report and the NOTICE OF RIGHTS on the reverse side of this form. I certify this amusement in compliance with §616.242, F.S. The employee responsible for operating this ride has been trained in accordance with F.S. and the manufacturers operating instructions or the operating fact sheats for this ride are available to the operator, lasttil4 daily inspection reports were completed and available u "Di_ ueq_ st._,-- Owner /Manager Signdture Inspector's Signature l/ ❑ PURSUANT TO Section 616242(7), FS., 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. 12/09 White /Bureau Canary/ Owner or Manager Pink/Event Inspection _ of Administrative Hearing Available If you wish to contest the Department's action, you have the right to request an administrative hearing to be conducted in accordance with Sections 120.569 and 120.57, Florida Statutes and to be represented by counsel or other qualified representative. Your request for hearing must contain: 1. Your name, address, and telephone number, and facsimile number (if any). 2. The name, address, and telephone number, and facsimile number of your attorney or qualified representative (if any) upon whom service of pleadings and other papers shall be made. 3. A statement that you are requesting an administrative hearing and dispute the material facts alleged by the department, in which case you must identify the material facts that are in dispute (formal hearing), or that you request an administrative hearing and that you do not dispute the facts alleged by the department (informal hearing). 4. A statement of when (date) you received this Notice and the file number of this Notice. Your request for a hearing must be received at the address shown on this Notice within twenty -one (21) days of receipt of this Notice. If you fail to obtain a Release from this Notice or fail to request an administrative hearing within the twenty -one (21) day deadline you waive your right to a hearing and the Department may enter a Final Order imposing up to the maximum penalties as authorized by Florida Law. I have read this notice of rights: SIGNATURE OF OWNER DATE DACS -03419 Rev. 12/09 ADAM H. PUTNAM COMMISSIONER DATA: Date inspector Event Location Florida Department of Agriculture and Consumer Services Division of. Consumer Services /Bureau of Fair Rides Inspection �c 9— AMUSEMENT RIDE INSPECTION REPORT Section 616.242(4), Florida Statutes Rule 5F- 8.0012, Florida Administrative Code Phone: 1- 800 -435 -7352; Fax: (850) 921 -1539 FairRides@FreshFromFlorida.com KIDDIE INN.KID11E Ride Owner Ride Name MFG Serial # USAID # Permit # SUPER lr REQUIREMENTS: (Check each requirement as it is accomplished or place (N) if not applicable) MOB eriti e4114144yc S id — Unannounced D c T f Re- inspection — Permit I TL '41-1 Inspection /Red Tag History � ciLA 1 O yt ( A - Permanent dil+ Location When Facing: Li 9%-- L itgc R. E C C\ a 1. RIDE STATUS a.( ermit b.( surance c. (mpliance /NDT d.( Manuals 4. ATTACHMENTS a.(, en Attachments b.(i frier/Tubs c.(straints v. d.(' Sweeps DEFICIENCIES: QAAT 'Wyk M * \ 2. INSTALLATION 8.( 01 king b.( ./Eeticing /Guarding c. (4aces /Guys /Anchors d.(,at'gns e.(4 Electrical 5. OPERATION a.(F3'M Check b.( Controls c.( Brakes d.( Limit Controls 3. STRUCTURAL a.( ,)1ipdrauiics /Pneumatics b.(rins /Bolts /Keys c.( SttucturalIntegrity d.( hTres/Wheels/Casters e.( /Bearings /Spindles /Axles f. ( Track/Rim Iron 6. OTHER a.(1-Automatic Sprinkler /Smoke Detector b.(!ater Quality c.(ungy Cords d.(i Cranes e.(9 Comments 4 tJ RESULTS: sx. p PURSUANT TO Section 616:242(7), F.S., AN INSPECTION CERTIFICATE IS ISSUED, when box is checked. The above identified amusement ride meets the requirements of Section 616242, 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) # % 0 -1 I acknowledge ride is §616242(16), and the receipt of this inspection report and the NOTICE OF RIGHTS on the reverse side of this form. I certify this amusement in compliance with §616.242, F.S. The employee responsible for operating this ride has been trained in accordance with F.S. and the manufacturers operating instructions or the operating fact sheets fo s ride are available to the operator, last 14 daily inspe on reports were completed and available upon �e LW ----VkP-S' Owner /Manager Sign Pure Inspector's Signature ❑ PURSUANT TO Section 616242(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. 12/09 White /Bureau Canary/ Owner or Manager Pink/Event Inspection - of Administrative Hearing Available If you wish to contest the Department's action, you have the right to request an administrative hearing to be conducted in accordance with Sections 120.569 and 120.57, Florida Statutes and to be represented by counsel or other qualified representative. Your request for hearing must contain: 1. Your name, address, and telephone number, and facsimile number (if any). 2. The name, address, and telephone number, and facsimile number of your attorney or qualified representative (if any) upon whom service of pleadings and other papers shall be made. 3. A statement that you are requesting an administrative hearing and dispute the material facts alleged by the department, in which case you must identify the material facts that are in dispute (formal hearing), or that you request an administrative hearing and that you do not dispute the facts alleged by the department (informal hearing). 4. A statement of when (date) you received this Notice and the file number of this Notice. Your request for a hearing must be received at the address shown on this Notice within twenty -one (21) days of receipt of this Notice. If you fail to obtain a Release from this Notice or fail to request an administrative hearing within the twenty -one (21) day deadline you waive your right to a hearing and the Department may enter a Final Order imposing up to the maximum penalties as authorized by Florida Law. I have read this notice of rights: SIGNATURE OF OWNER DATE DACS -03419 Rev. 12/09 ADAM H.PUTNAM' COMMISSIONER DATA: Date. Inspector Event Location Florida_ Department of Agriculture and Consumer Services; Division of Consumer Services /Bureau of Fair Rides Inspection AMUSEMENT RIDE INSPECTION REPORT Section 616242(4), Florida Statutes Rule 5F- 8.0012, Florida Administrative Code Phone: 1- 800 -435 -7352; Fax (850) 921 -1539 FairRides@FreshFromFlorida.com /— Li— (7 Ilmtv; 0J cS KIDDIE NKID E REQUIREMENTS (Check each requirement as it is accomplished or place (N) if not applicable) Ride Owner ,M o er-v kfi M Ride Name o c ,1A,I I t MFG .11 8r id t Serial # USAID # Permit # SUPER fiele'd - Unannounced Re- inspection — Permit Inspection /Red Tag History grip a — Permanent Location When Facing: e 001- R. t\l'.101,2..Er2.-te_ 41 Sc 1. RIDE STATUS a.( it b.( s urance c.(mpliance /NDT d.(Manuals 4. ATTACHMENTS a.( ) Gen Attachments b.( ')Carrier/Tubs_- c.( < ',Restraints d.(r) Sweeps DEFICIENCIES: 4 JO k (,)\et! 100-1V CA)\--EhOSet4;g4-9 , co \ \o c. v °+n �,a A 1 ` � � .� ► `a te a r Q i ec D C r . 1 roo k_41 t401-- 2. INSTALLATION a.( cking b.( e ncing /Guarding c.(4 aces /Guys /Anchors d.( � 4, s e.( 'Electrical 5. OPERATION a.( 1VM Check b.( Controls c.( Brakes d.( Limit Controls 3. STRUCTURAL a (4draulics /Pneumatics. b( -Ps /Bolts /Keys c c.(14r4actural Integrity d.( s/Wheels /Casters e.( Oearings/Spindles/Axles f. oTrack/Rim Iron 6. OTHER a. 4` utomatic Sprinkler /Smoke Detector b:(ater Quality c.r4 Stingy Cords d.(< C "nes e.(�mments er RESULTS: DACS- 03419 Rev. 12/09 White /Bureau Canary/ Owner or Manager Pink/Event Inspection _ of PURSUANT TO Section 616242(7), F.S., AN INSPECTION CERTIFICATE IS ISSUED, when box is checked. The above identified amusement ride meets the requirements of Section 616242, 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) # ! 77 I acknowledge ride is §616242(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 RS. and the manufacturers operating instructions or the operating fact sheets f -this ride are available to the operator, last 14 daily inspection reports were completed and available upon rimes cni 27,'1:14. &I 1,144 r, Owner /Manager Sign rture Inspector's Signature PURSUANT TO Section 616242(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. 12/09 White /Bureau Canary/ Owner or Manager Pink/Event Inspection _ of Administrative Hearing Available If you wish to contest the Department's action, you have the right to request an administrative hearing to be conducted in accordance with Sections 120.569 and 120.57, Florida Statutes and to be represented by counsel or other qualified representative. Your request for hearing must contain: 1. Your name, address, and telephone number, and facsimile number (if any). 2. The name, address, and telephone number, and facsimile number of your attorney or qualified representative (if any) upon whom service of pleadings and other papers shall be made. 3. A statement that you are requesting an administrative hearing and dispute the material facts alleged by the department, in which case you must identify the material facts that are in dispute (formal hearing), or that you request an administrative hearing and that you do not dispute the facts alleged by the department (informal hearing). 4. A statement of when (date) you received this Notice and the file number of this Notice. Your request for a hearing must be received at the address shown on this Notice within twenty -one (21) days of receipt of this Notice. If you fail to obtain a Release from this Notice or fail to request an administrative hearing within the twenty -one (21) day deadline you waive your right to a hearing and the Department may enter a Final Order imposing up to the maximum penalties as authorized by Florida Law. I have read this notice of rights: SIGNATURE OF OWNER DATE DACS -03419 Rev. 12/09 ADAM H. PUTNAM COMMISSIONER � I Florida Department`ofAgriculture and'Gonsumer Services Division of 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: 1- 800 -435 -7352; Fax: (850) 921 -1539 FairRides@FreshFromFlorida.com DATA: Date l% J -V 0 - Inspector Event ST 6 Location NON - KIDDIE Ride Owner Ride Name MFG Serial # USAID # Permit # SUPER 41 o6er4i 4(i I /3kids - Ili Y trk r I i --111_01-- Unannounced Re- inspection - Permit Inspection /Red Tag History - po�atry Permanent Location When Facing: L. P9 R. 7 REQUIREMENTS: (Check each requirement as it is accomplished or place (N) if not applicable), 1. RIDE STATUS a.(F? rmit b.(urance c.( mpliance /NDT d.1 ( 1Manuals 4. ATTACHMENTS a.(4-ten Attachments b.( (�arrier/Tubs c.((Restraints d.(Sweeps DEFICIENCIES: 2. INSTALLATION a.,yjocking b.(.j Fencing /Guarding c ((races /Guys /Anchors d (��r -Signs e.(1 Electrical 5. OPERATION a.( 'F3FM Check b.(introls c.( 1Srakes d.(4Limit Controls 6..). 4j, 3..STIUCTURAL a.( Hydraulics /Pneumatics b.(s /Bolts /Keys c.(j S ructural Integrity d.( T,ires/Wheels /Casters e.( /rBearings /Spindles /Axles f. O'Track/Rim Iron 6.OTHER a. (- 'Automatic Sprinkler /Smoke Detector b.(l Water Quality c.('Bgy Cords d. (-� 'Cranes e.Vj'Comments RESULTS: DACS -03419 Rev. 12/09 White /Bureau Canary/ Owner or Manager pink/Event 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 616242, 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 7-01 I acknowledge ride is §616.242(16), and the receipt of this inspection report and the NOTICE OF RIGHTS on the reverse side of this form. I certify this amusement in compliance with §616.242, F.S. The employee responsible for operating this ride has been trained in accordance with F.S. and the manufacturers operating instructions or the operating fact sheets for this ri e are available to the operator, last 14 daily inspection reports were completed and available upon request. Owner /Manager Signature Inspector's Signature o PURSUANT TO Section 616.242(7), F.S., the above identified amusement ride does not meet the requirements of Section 616.242, F.S. and Chapter 5F-8, F.A.C. and shall not operate until it passes a subsequent inspection by the Department. STOP OPERATION ORDER (DACS 03545, Rev. 12/09) Owner /Manager Signature Inspector's Signature DACS -03419 Rev. 12/09 White /Bureau Canary/ Owner or Manager pink/Event Inspection. _ of Administrative Hearing Available If you wish to contest the Department's action, you have the right to request an administrative hearing to be conducted in accordance with Sections 120.569 and 120.57, Florida Statutes and to be represented by counsel or other qualified representative. Your request for hearing must contain: 1. Your name, address, and telephone number, and facsimile number (if any). 2. The name, address, and telephone number, and facsimile number of your attorney or qualified representative (if any) upon whom service of pleadings and other papers shall be made. 3. A statement that you are requesting an administrative hearing and dispute the material facts alleged by the department, in which case you must identify the material facts that are in dispute (formal hearing), or that you request an administrative hearing and that you do not dispute the facts alleged by the department (informal hearing). 4. A statement of when (date) you received this Notice and the file number of this Notice. Your request for a hearing must be received at the address shown on this Notice within twenty -one (21) days of receipt of this Notice. If you fail to obtain a Release from this Notice or fail to request an administrative hearing within the twenty -one (21) day deadline you waive your right to a hearing and the Department may enter a Final Order imposing up to the maximum penalties as authorized by Florida Law. have read this notice of rights: SIGNATURE OF OWNER DATE DACS -03419 Rev. 12/09 ADAM H. PUTNAM COMMISSIONER DATA: Date Inspector Event Location Florida Department of Agriculture and Consumer Services Division of Consumer Services /Bureau of Fair Rides Inspection AMUSEMENT RIDE INSPECTION REPORT Section 616.242(4), Florida Statutes Rule 5F- 8.0012, Florida Administrative Code / -I (L& O f Prof, E Phone: 1- 800 -435 -7352; Fax: (850) 921 -1539 FairRides @FreShFromFlorida. com Ride Owner - A° ae kd i /J Ride Name 4l MFG Serial # USAID # Permit # Mae NON- KIDDIE SUPER REQUIREMENTS: (Check each requirement as it is accomplished or place (N) if not applicable) LI�!F ooh �cTied} led - Unannounced Re-inspection - Permit Inspection /Red Tag History -- Tent-OT 'y - Permanent Location When Facing: L. ®c r R. -TRA 1. RIDE STATUS a.( 't?ermit b.( Insurance c.( pliance /NDT d.( Manuals 4. ATTACHMENTS a.(n Attachments b.( zr Carrier/Tubs c.( fR��__ints d.( weeps DEFICIENCIES: 2. INSTALLATION a.(3tocking b.(4-Fencing/Guarding c.( aces /Guys /Anchors d.( - s e.( Electrical 5. OPERATION a.( rM Check b.(ntrols c.( es d.( Limit Controls 3. STRUCTURAL a.( —)`, draulics /Pneumatics b.( r1s /Bolts /Keys c.( (: P uctural Integrity d.(/- Tifes/Wheels /Casters e.(� (wrings /Spindles /Axles f. (4- Track/Rim Iron 6. OTHER a.(c-)tomatic Sprinkler /Smoke Detector b.(4Water Quality c.(�Bungy Cords d,(.JG nes e.(- 'Comments RESULTS: Fc/ 4 S i DACS -03419 Rev. 12/09 White /Bureau Canary/ Owner or Manager Pink/Event Inspection of PURSUANT TO Section 616242(7), F.S., AN INSPECTION CERTIFICATE 15 ISSUED, when box is checked. The above identified amusement ride meets the requirements of Section 616242, 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) # /) a)7 !acknowledge ride is §616242(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 §616242, F.S. The employee responsible for operating this ride has been trained in accordance with F.S. and the manufacturers operating instructions or the operating fact sheets is ride are available to the operator, lasti4 daily inspection reports were completed and available upot egu t `\ Owner /Manager Sigrrature Inspecto .s Signature ❑ PURSUANT TO Section 616242(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. 12/09 White /Bureau Canary/ Owner or Manager Pink/Event Inspection of Administrative Hearing Available If you wish to contest the Department's action, you have the right to request an administrative hearing to be conducted in accordance with Sections 120.569 and 120.57, Florida Statutes and to be represented by counsel or other qualified representative. Your request for hearing must contain: 1. Your name, address, and telephone number, and facsimile number (if any). 2. The name, address, and telephone number, and facsimile number of your attorney or qualified representative (if any) upon whom service of pleadings and other papers shall be made. 3. A statement that you are requesting an administrative hearing and dispute the material facts alleged by the department, in which case you must identify the material facts that are in dispute (formal hearing), or that you request an administrative hearing and that you do not dispute the facts alleged by the department (informal hearing). 4. A statement of when (date) you received this Notice and the file number of this Notice. Your request for a hearing must be received at the address shown on this Notice within twenty -one (21) days of receipt of this Notice. If you fail to obtain a Release from this Notice or fail to request an administrative hearing within the twenty -one (21) day deadline you waive your right to a hearing and the Department may enter a Final Order imposing up to the maximum penalties as authorized by Florida Law. I have read this notice of rights: SIGNATURE OF OWNER DATE DACS -03419 Rev. 12/09 ADAM H. PUTNAM COMMISSIONER DATA: Date Inspector Event Location Florida DepartMer1t of Agriculture and Consumer Services° Division of Consumer Services /Bureau of Fair Rides Inspection AMUSEMENT RIDE INSPECTION REPORT Section 616.242(4), Florida Statutes Rule 5F- 8.0012, Florida Administrative Code. Co Avo RoS E NON - KIDDIE Phone: 1- 800 - 435 -7352; Fax: (850) 921 -1539 FairRides@FreshFromFlorida.com Ride Owner Ride Name MFG Serial # USAID # Permit # SUPER 7 dc-' 4- 1A1I6�'�� e' MRR/ d. 76.7- lo Aip Of' i Sol° 9'0-701 L 0 � educed - Unannounced Re- inspection — Permit Inspection /Red Tag History° Tempos - Permanent Location When Facing: L. 4 R. .- REQUIREMENTS: (Check each requirement as it is accomplished or place (N) if not applicable) 1. RIDE STATUS a.( ' mit b.( Insurance c.(pmpliance /NDT d.( Manuals 4. ATTACHMENTS a.(en Attachments b.(4-Carrier/Tubs c.( traints d.( Sweeps DEFICIENCIES: 2. INSTALLATION a.( "Stocking b.(, TF ncing /Guarding c.( Braces /Guys /Anchors d.( i e.(.yt Iectrical 5. OPERATION a.(#RM Check b.( 6ontrols c: (fir kes d.( imit Controls 3. STRUCTURAL a.( ydraulics /Pneumatics b.( ) Pis /Bolts /Keys c.( TStnictural Integrity d.( : rires/Wheels /Casters e.(-'Bearings /Spindles /Axles f. (,,Track/Rim Iron 6.OT) ER a.( -) Automatic Sprinkler /Smoke Detector b.(ater Quality c.(4Sungy Cords d.(> Qranes e.(1-Comments ats c ,:,r ,- r 'rlrr(R ) RESULTS: DACS -03419 Rev. 12/09 White /Bureau Canary/ Owner or Manager Pink/Event 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 616242, 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) # i1 0-1 q k 1 acknowledge ride is §616242(16), and the receipt of this inspection report and the NOTICE OF RIGHTS on the reverse side of this form. J certify this amusement in compliance with §616242, FS. The employee responsible for operating this ride has been trained in accordance with F.S. and the manufacturers operating instructions or the operating fact sheets for this ride are available to the operator, lasttt4 daily inspec ion reports were completed and available upon request. 7-- Owner /Manager Signature Inspector's Signature ❑ PURSUANT TO Section 616242(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. 12/09 White /Bureau Canary/ Owner or Manager Pink/Event Inspection — of Administrative Hearing Available If you wish to contest the Department's action, you have the right to request an administrative hearing to be conducted in accordance with Sections 120.569 and 120.57, Florida Statutes and to be represented by counsel or other qualified representative. Your request for hearing must contain: 1. Your name, address, and telephone number, and facsimile number (if any). 2. The name, address, and telephone number, and facsimile number of your attorney or qualified representative (if any) upon whom service of pleadings and other papers shall be made. 3. A statement that you are requesting an administrative hearing and dispute the material facts alleged by the department, in which case you must identify the material facts that are in dispute (formal hearing), or that you request an administrative hearing and that you do not dispute the facts alleged by the department (informal hearing). 4. A statement of when (date) you received this Notice and the file number of this Notice. Your request for a hearing must be received at the address shown on this Notice within twenty -one (21) days of receipt of this Notice. If you fail to obtain a Release from this Notice or fail to request an administrative hearing within the twenty -one (21) day deadline you waive your right to a hearing and the Department may enter a Final Order imposing up to the maximum penalties as authorized by Florida Law. I have read this notice of rights: SIGNATURE OF OWNER DATE DACS -03419 Rev. 12/09 ADAM H. PUTNAM COMMISSIONER Florida Department of Agriculture and Consumer Services Division of 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: 1- 800 -435 -7352; Fax: (850) 921 -1539 FairRides@FreshFromFlorida.com DATA: Date t Inspector Event Location M.e P. Wit; -\ 75\-- 5 r_ oS% Ride Owner Mo t 0 ),,kr Ride Name MFG PO s\ o) Woe C ®O Serial # USAID # Permit # KIDDI NON- KIDDIE SUPER REQUIREMENTS: (Check each requirement as it is accomplished or place (N) if not applicable) tVAoci 0 etc of Unannounced Re- inspection - Permit Inspection /Red Tag History Torary, - Permanent Location When Facing: L. ® R. lad 1. RIDE STATUS a.(ermit b.( eYirisurance c.( ompliance/NDT d.( Manuals 4. ATTACHMENTS a.( Attachments b.( 4Carrier/Tubs c. (Restraints d.( 4 Sweeps DEFICIENCIES: 2. INSTALLATION a.( locking b.(<0fFencing /Guarding c.(+.[ races /Guys /Anchors d.(-1-Signs e.( ' Iectrical 5. OPERATION a.( t M Check b.(,d- Qntrols c.(rakes d.( m it Controls 3: STRUCTURAL a.(Hrdraulics /Pneumatics b.(, P_ijn. s /Bolts /Keys c.(') Structural Integrity d. (4 tites/W heels /Casters e.( Hearings /Spindles /Axlds f. (44rack/Rim Iron 6.OTHER a.(AUtomatic Sprinkler /Smoke Detector b.(4Water Quality c.(4bj. ngy Cords d.( � arses e.(�j"'Comments RESULTS: ) 1cI`r�� S. A1csTJ3 MACS -03419 Rev. 12/09 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\ 'c q I- b I acknowledge ride is §616242(16), and the receipt of this inspection report and the NOTICE OF RIGHTS on the reverse side of this form. I certify this amusement in compliance with §616.242, F.S. The employee responsible for operating this ride has been trained in accordance with F.S. and the manufacturers operating instructions or the operating fact sheets for thi:qde are available to the operator, last 14 daily ins ection reports were completed and available upon rear -: ---- Owner /Manager Signature Inspector's Signature ❑ PURSUANT TO Section 616242(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 MACS -03419 Rev. 12/09 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. have read this notice of rights: SIGNATURE OF OWNER DATE DACS -03419 Rev. 12/09 ADAM H. PUTNAM COMMISSIONER DATA: Date Inspector Event Location Florida Department of Agriculture and Consumer Services Division of 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: 1- 800 - 435 -7352; Fax: (850) 921 -1539 FairRides @FreshFromFlorida.com Ride Owner Ride Name MFG Serial # USAID # Permit # KIDDIE WO DIE SUPER rr7-. 6 (J1JI/ �C)l f0 a' 3cheduled.-01 Unannounced Re- inspection Permit Inspection /Red Tag History T mpoa ry— Permanent Location When Facing: L. e. REQUIREMENTS: (Check each requirement as it is accomplished or place (N) if not applicable) 1`._RID,E STATUS a.(44)ermit b.( Thsurance c.( mpliance /NDT d.( Manuals 4. ATTACHMENTS a.(Gen Attachments b.( ,arner/Tubs c.(`straints d,(,4/sweeps DEFICIENCIES: 2. INSTALLATION a.( king b.( 'F�ing /Guarding c.( Braces /Guys /Anchors d.( e.( lectrical 5. OPERATION a.('M Check b.(1 Controls c.( 4takes d.( imit Controls pV Le_ Ors 3. STRUCTURAL a.( ydraulics /Pneumatics b.(�s /Bolts /Keys c.( i Structural Integrity d.( %=t' resiWheels /Casters e.( 4 Bearings /Spindles /Axles f. (4Track/Rim Iron 6. OTHER a.(4Automatic Sprinkler /Smoke Detector b.(;GaterQuality c.(„-.ungy Cords d.(.4'Cranes e.(4tomments oc.of _fi ✓�® RESULTS: DACS -03419 Rev. 12/09 White/Bureau Canary/ Owner or Manager Pink/Event Inspection _ of PURSUANT TO Section 616242(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) # f 3-7 I acknowledge ride is §616.242(16), and the receipt of this inspection report and the NOTICE OF RIGHTS on the reverse side of this form. I certify this amusement in compliance with §616.242, F.S. The employee responsible for operating this ride has been trained in accordance with F.S. and the manufacturers operating instructions or the operating fact sheets for this ride are available to the operator, last 14 daily inspection reports were completed and available upon request. Q ,- Owner /Manager Signature Inspector's Signature_ ❑ PURSUANT TO Section 616242(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. 12/09 White/Bureau Canary/ Owner or Manager Pink/Event Inspection _ of Administrative Hearing Available If you wish to contest the Department's action, you have the right to request an administrative hearing to be conducted in accordance with Sections 120.569 and 120.57, Florida Statutes and to be represented by counsel or other qualified representative. Your request for hearing must contain: 1. Your name, address, and telephone number, and facsimile number (if any). 2. The name, address, and telephone number, and facsimile number of your attorney or qualified representative (if any) upon whom service of pleadings and other papers shall be made. 3. A statement that you are requesting an administrative hearing and dispute the material facts alleged by the department, in which case you must identify the material facts that are in dispute (formal hearing), or that you request an administrative hearing and that you do not dispute the facts alleged by the department (informal hearing). 4. A statement of when (date) you received this Notice and the file number of this Notice. Your request for a hearing must be received at the address shown on this Notice within twenty -one (21) days of receipt of this Notice. If you fail to obtain a Release from this Notice or fail to request an administrative hearing within the twenty -one (21) day deadline you waive your right to a hearing and the Department may enter a Final Order imposing up to the maximum penalties as authorized by Florida Law. I have read this notice of rights: SIGNATURE OF OWNER DATE DACS -03419 Rev. 12/09 h'. Florida Department of Agriculture and Consumer Services Division of Consumer Services /Bureau of Fair Rides Inspection AMUSEMENT RIDE INSPECTION REPORT Section 616.242(4), Florida Statutes Rule 5F- 8.0012, Florida Administrative Code ADAM H. PUTNAM COMMISSIONER DATA: Date e a.p / 7 Inspector m p co Event VT 1- o . E7 Location Phone: 1- 800- 435 -7352; Fax: (850) 921 -1539 FairRides @FreshFromFlorida.com Ride Owner Ride Name MFG Serial # USAID # Permit # KIDDIE NON - KIDDIE REQUIREMENTS: (Check each requirement as it is accomplished or place (N) if not applicable) 1. RIDE STATUS a.( rmit b.( I urance c.( mpliance /NDT d.( Manuals Moherp) A4' , W4' c f Ifx CAA ( em 4:4 of e u d — Unannounced Re- inspection — Permit Inspection /Red Tag History -� Tem r — Permanent Location When Facing: L. a' s R. a s f`6`0 4. ATTACHMENTS a.( Gen Attachments b.(.arrier/Tubs c.( 413estraints d.( YS'weeps DEFICIENCIES: 2. INSTALLATION a.(Btocking b.(Fencing /Guarding c.( laces /Guys /Anchors d.( s e.( Electrical 5. OPERATION a.(4RPM Check b.(gcontrols c.( 'rakes d.(,yLmit Controls r 3.STRUCTURAL a .( 9 draulics /Pneumatics b.(ins /Bolts /Keys c.(4S� cturalIntegrity d. (47iwes/W h eels /Casters e.( 4 Bearings /Spindles /Axles f. (4track/Rim Iron 6.O TAMER a a.(--Y,Automatic Sprinkler /Smoke Detector b.(-ater Quality c.O ungy Cords d.( )Cranes e.( Comments ,jDC I ft l tFSULTS: n DACS-03419 Rev. 12/09 White /Bureau Canary/ Owner or Manager Pink/Event 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) # 8 rfi'' 7 Ica I acknowledge ride is §616242(16), and the receipt of this inspection report and the NOTICE OF RIGHTS on the reverse side of this form. 1 certify this amusement in compliance with §616.242, F.S. The employee responsible for operating this ride has been trained in accordance with F.S. and the manufacturers operating instructions or the operating fact sheets fhs ride are available to the operator; last 14 daily inspection reports were completed and available upo 're Owner /Manager Signature Inspector's Sign ture o PURSUANT TO Section 616242(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. 12/09 White /Bureau Canary/ Owner or Manager Pink/Event Inspection _ of Administrative Hearing Available If you wish to contest the Department's action, you have the right to request an administrative hearing to be conducted in accordance with Sections 120.569 and 120.57, Florida Statutes and to be represented by counsel or other qualified representative. Your request for hearing must contain: 1. Your name, address, and telephone number, and facsimile number (if any). 2. The name, address, and telephone number, and facsimile number of your attorney or qualified representative (if any) upon whom service of pleadings and other papers shall be made. 3. A statement that you are requesting an administrative hearing and dispute the material facts alleged by the department, in which case you must identify the material facts that are in dispute (formal hearing), or that you request an administrative hearing and that you do not dispute the facts alleged by the department (informal hearing). 4. A statement of when (date) you received this Notice and the file number of this Notice. Your request for a hearing must be received at the address shown on this Notice within twenty -one (21) days of receipt of this Notice. If you fail to obtain a Release from this Notice or fail to request an administrative hearing within the twenty -one (21) day deadline you waive your right to a hearing and the Department may enter a Final Order imposing up to the maximum penalties as authorized by Florida Law. I have read this notice of rights: SIGNATURE OF OWNER DATE DACS -03419 Rev. 12/09 ADAM H. PUTNAM COMMISSIONER DATA: Date Inspector Event Location. Florida Department of Agriculture and Consumer Services'` 2 Division of 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: 1- 800 -435 -7352; Fax: (850) 921.1539 FairRides@FreshFromFlorida.com Ride Owner Ride Name a Q MFG Serial # USAID # Permit # KIDDIE NON KID'IE SUPER REQUIREMENTS: (Check each requirement as it is accomplished or place (N) if not applicable) ikeoviLid ti 8/ 4 (, b . Li919 4n"� sheiu d — Unannounced Re- inspection - Permit Inspection /Red Tag History mpor- Permanent - Location When Facing: L.( %t R. 1. RID STATUS. a.( rmit b.( ipsurance c.( Tupmpliance /NDT d.(. Manuals 4. ATTACHMENTS a.(49en Attachments b.( carrier/Tubs c.( s`traints d.( Sweeps DEFICIENCIES: 2. INSTALLATION. a.(,Locking b.( 4encing/Guarding c.( saces/Guys/Anchors d.(1 Signs e.( 'Electrical 5. OPERATION a.( PM Check b.( ontrols c.( fB.r kes d.( 'Limit Controls 3. STRUCTURAL a.(,) (draulics /Pneumatics b.( P' - s /Bolts /Keys c.( ¶ Structural Integrity d.( f )tres/Wheels /Casters e.( ') Searings /Spindles /Axles f. ( 1Track/Rim Iron 6.OTHER r utomatic Sprinkler /Smoke Detector b.(4 ater Quality c.(ungy Cords d.(4 / cranes e.(4Comments RESULTS: DACS-03419 Rev. 12/09 White /Bureau Cana■/ Owner or Manager Pink/Event 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 616242, 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) # il 0 '7s `7 -Ji I acknowledge ride is §616242(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 §616242, F.S. The employee responsible for, operating this ride has been trained in accordance with F.S. and the manufacturers operating instructions or the operating fact sheets for this ride are available to the operator, last 14 daily inspection reports were completed and available upon request. �p rik- Owner /Manager Signature Inspector's Signature PURSUANT TO Section 616242(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. 12/09 White /Bureau Cana■/ Owner or Manager Pink/Event Inspection of Administrative Hearing Available If you wish to contest the Department's action, you have the right to request an administrative hearing to be conducted in accordance with Sections 120.569 and 120.57, Florida Statutes and to be represented by counsel or other qualified representative. Your request for hearing must contain: 1. Your name, address, and telephone number, and facsimile number (if any). 2. The name, address, and telephone number, and facsimile number of your attorney or qualified representative (if any) upon whom service of pleadings and other papers shall be made. 3. A statement that you are requesting an administrative hearing and dispute the material facts alleged by the department, in which case you must identify the material facts that are in dispute (formal hearing), or that you request an administrative hearing and that you do not dispute the facts alleged by the department (informal hearing). 4. A statement of when (date) you received this Notice and the file number of this Notice. Your request for a hearing must be received at the address shown on this Notice within twenty -one (21) days of receipt of this Notice. If you fail to obtain a Release from this Notice or fail to request an administrative hearing within the twenty -one (21) day deadline you waive your right to a hearing and the Department may enter a Final Order imposing up to the maximum penalties as authorized by Florida Law. I have read this notice of rights: SIGNATURE OF OWNER DATE DACS -03419 Rev. 12/09 ADAM H. PUTNAM COMMISSIONER DATA: Florida Department of Agricultial=e and tonsurr er SdrVloes` Division of 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: 1- 800 -435- 7352; Fax: (850) 921 -1539 FairRides @FreshFromFlorida.com Date — k T Ride Owner M 9Nei c) YA,WA I etI I – Unannounced Inspector Ride Name ,1 r A cczi 0 „) VAV V \ C 00 Re- inspection – Permit Event -- R, ; F_ MFG W k S a 0 leA C Inspection /Red Tag History Location Serial # , (?':_9 ),4S„)Vj"Ytt'Terpofa- Permanent USAID # 7', c 9 Location When Facing Permit # �.�� < <i L. R. KIDDIE NO,3 =1(�IE SUPER REQUIREMENTS: (Check each requirement as it is accomplished or place (N) if not applicable) 1. RIDE STATUS a.(-1f1 ermit b.( Insurance c.( compliance /NDT d.(anuals 4. ATTACHMENTS a.(en Attachments b.( 4rrier/Tubs c.( restraints d.( weeps DEFICIENCIES: 2. INSTALLATION a.( J ocking b.(1-Fencing/Guarding c. (races/Guys/Anchors d.( 'gns e.( Electrical 5. OPERATION a.(4PM Check b.(� Controls c.(akes d.(mit Controls 1(„L O, 4 '/oe it'/ �. e 3. STRUCTURAL a.( 4 hydraulics /Pneumatics b.(4Pets /Bolts /Keys c.( tructural Integrity d( 41 res/W heels /Casters e. (,)*arings /Spindles /Axles f. Track/Rim Iron 6. OTHER a.(0°qutomatic Sprinkler /Smoke Detector b.(4 A/ater Quality c.r - )BungyCords d.(4,ranes e.(Atomments OA/ s ACC, 6 PI ,, c & OR,” c e;.r RESULTS: DACS -03419 Rev. 12/09 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 616242, 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) # li C 0-7q4 I acknowledge ride is §616.242(16), and the receipt of this inspection report and the NOTICE OF RIGHTS on the reverse side of this form. I certify this amusement in compliance with §616.242, F.S. The employee responsible for operating this ride has been trained in accordance with F.S. and the manufacturers operating instructions or the operating fact sheets for this ride are available to the operator, last14 daily inspec n reports were completed and available upon request. Owner /Manager Signatures Inspector's Signature ❑ PURSUANT TO Section 616242(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. 12/09 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. 12/09 ADAM H. PUTNAM COMMISSIONER DATA: Date Inspector Event Location Florida Department of Agriculture'and Consumer Services Division of 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: 1- 800 -435 -7352; Fax: (850) 921 -1539 FairRides@FreshFromFlorida.com Ride Owner Ride Name MFG Serial # Moleiet, GrA USAID # Permit # t_B E-,° SUPER KIDDIE J II REQUIREMENTS: (Check each requirement as it is accomplished or place (N) if not applicable) S'Eh dam- Unannounced Re- inspection — Permit Inspection /Red Tag History Tot — Permanent Location When Facing: L. 13/2.1--' R. 6. 1. RIDE STATUS a.( emit b.( fl - urance" c.( mpliance /NDT d.( Manuals 4. ATTACHMENTS a.( O Gen Attachments b44parrier/Tubs c.( Restraints d.( Sweeps_ DEFICIENCIES: w 6f ea a-d e-et Alert-° r� 2. INSTALLATION a.(, )4ocking b.(. Wincing /Guarding c ( Braces /Guys /Anchors d.(S igns e.( Electrical 5. OPERATION a. M Check b.(. ; ontrols c.( B kes d.( Limif Controls P ,- 1'.3'fv /U gcr c, . /s1 ',.4 31'40' .i'' 3. STRUCTURAL a.( Hydraulics /Pneumatics b.( 1P s /Bolts /Keys c.(4 tructural Integrity d.( tires/Wheels/Casters e.(, arings /Spindles /Axles f. (s Track/Rim Iron 6.OT)IE R a.(utomatic Sprinkler /Smoke Detector b.( ater Quality c.(4)ungy Cords d.(1anes e.(Comments '7)6 ( (Zol- 0 eLpz ` tl v/z. f7G) cyan. " RESULTS: DACS -03419 Rev. 12/09 White /Bureau Canary/ Owner or Manager Pink/Event 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) # , cr7 c"�, 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. and the manufacturers operating instructions or the operating fact sheets for this ride are available to the operator, last 14 daily inspection reports were completed and available upon request. c? i .ti �` s c) ,ei Owner /Manager—Signatd`re Inspector's Signature. o PURSUANT TO Section 616242(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. 12/09 White /Bureau Canary/ Owner or Manager Pink/Event Inspection _ of _ Administrative Hearing Available If you wish to contest the Department's action, you have the right to request an administrative hearing to be conducted in accordance with Sections 120.569 and 120.57, Florida Statutes and to be represented by counsel or other qualified representative. Your request for hearing must contain: 1. Your name, address, and telephone number, and facsimile number (if any). 2. The name, address, and telephone number, and facsimile number of your attorney or qualified representative (if any) upon whom service of pleadings and other papers shall be made. 3. A statement that you are requesting an administrative hearing and dispute the material facts alleged by the department, in which case you must identify the material facts that are in dispute (formal hearing), or that you request an administrative hearing and that you do not dispute the facts alleged by the department (informal hearing). 4. A statement of when (date) you received this Notice and the file number of this Notice. Your request for a hearing must be received at the address shown on this Notice within twenty -one (21) days of receipt of this Notice. If you fail to obtain a Release from this Notice or fail to request an administrative hearing within the twenty -one (21) day deadline you waive your right to a hearing and the Department may enter a Final Order imposing up to the maximum penalties as authorized by Florida Law. I have read this notice of rights: SIGNATURE OF OWNER DATE DACS -03419 Rev. 12/09 ADAM H. PUTNAM COMMISSIONER DATA: Date Inspector Event Location Florida Department of Agriculture and Consumer Services Division of 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: 1 -800 -435 -7352; Fax: (850) 921 -1539 FairRides @FreshFromFlorida.com Ride Owner Ride Name MFG Serial # USAID # Permit # KIDDIE Nf4CIE SUPER REQUIREMENTS: (Check each requirement as it is accomplished or place (N) if not applicable) y r � y -� � -7 960 >Zched`u'- Unannounced Re- inspection - Permit Inspection /Red Tag History mpaty - Permanent 'to-Cation When Facing: L. c, R.0 F 1. RIDE-STATUS a.(cf'Permit b.( 41 surance c.( Compliance /NDT d.( Manuals 4. ATTACHMENTS a. (A-'fye n Attachments b.( Carrier/Tubs c.( straints d.( 'Sweeps DEFICIENCIES: 2. INSTALLATION a.(44locking b.(ncing /Guarding c.( ,yiVaces/Guys/Anchors d.( ftigns e.( 4- lectrical 5. OPERATION a.O'-RPM Check b.( Controls c.(---f-Brakes d.( ,Limit Controls toir% 4o 3. STRUCTURAL a.(4 draulics /Pneum atics b.( s /Bolts /Keys c.( '$tructuralIntegrity d.(iy esM/heels /Casters e. (parings /Spindles /Axles f. ((4%frack/Rim Iron J 6. OTHER a.(� Automatic Sprinkler /Smoke Detector b b.(4.rAtater Quality c.(gBungy Cords d.( Crrnes e.(,- omments RESULTS: DACS -03419 Rev. 12/09 White/Bureau Canary/ Owner or Manager Pink/Event 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 616242, 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) # p o -7 ci I acknowledge ride is §616.242(16), and the receipt of this inspection report and the NOTICE OF RIGHTS on the reverse side of this form. I certify this amusement in compliance_ with §616.242, F.S. The employee responsible for operating this ride has been trained in accordance with F.S, and the manufacturers operating instructions or the operating fact sh ets for this ride are available to the operator, las 14 daily inspection reports were completed and available upon_ Gi ? ^i,; tikAi Owner /Manager Signature Inspector's Signature PURSUANT TO Section 616.242(7), F.S., the above identified amusement ride does not meet the requirements of Section 616.242, F.S. and Chapter 5F -8, F.A.C. and shall not operate until it passes a subsequent inspection by the Department. STOP OPERATION ORDER (DACS 03545, Rev. 12/09) # Owner /Manager Signature Inspector's Signature DACS -03419 Rev. 12/09 White/Bureau Canary/ Owner or Manager Pink/Event Inspection _ of Administrative Hearing Available If you wish to contest the Department's action, you have the right to request an administrative hearing to be conducted in accordance with Sections 120.569 and 120.57, Florida Statutes and to be represented by counsel or other qualified representative. Your request for hearing must contain: 1. Your name, address, and telephone number, and facsimile number (if any). 2. The name, address, and telephone number, and facsimile number of your attorney or qualified representative (if any) upon whom service of pleadings and other papers shall be made. 3. A statement that you are requesting an administrative hearing and dispute the material facts alleged by the department, in which case you must identify the material facts that are in dispute (formal hearing), or that you request an administrative hearing and that you do not dispute the facts alleged by the department (informal hearing). 4. A statement of when (date) you received this Notice and the file number of this Notice. Your request for a hearing must be received at the address shown on this Notice within twenty -one (21) days of receipt of this Notice. If you fail to obtain a Release from this Notice or fail to request an administrative hearing within the twenty -one (21) day deadline you waive your right to a hearing and the Department may enter a Final Order imposing up to the maximum penalties as authorized by Florida Law. I have read this notice of rights: SIGNATURE OF OWNER DATE DACS -03419 Rev. 12/09 ADAM H. PUTNAM COMMISSIONER DATA: Date Inspector Event Location Florida Department of Agriculture and'Consumer Services' Division of 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: 1- 800 -435 -7352; Fax: (850) 921 -1539 FairRides @FreshFromFlorida.com Ride Owner Ride Name MFG Serial # USAID # Permit # <; 4/d t-rJ/ t t o V q (� Sc e u d — Unannounced Re- inspection — Permit Inspection /Red Tag History porarjr — Permanent Location When Facing: L. ate' per` C. R. KIDDIE NON- KIDDIE ic REQUIREMENTS: (Check each requirement as it is accomplished or place (N) if not applicable) 1. RIDE STATUS a.( rmit b.(1urance. c.( 3 ompliance /NDT d.( ATTACHMENTS a.( -en Attachments b.( jarrier/Tubs c.( 4estraints d.(, 'Sweeps DEFICIENCIES: da 2. INSTALLATION a.(4- Stocking b.(ncing /Guarding c.(races /Guys /Anchors d.( 'ffitgns e.( Electrical 5. OPERATION a.(:4 M Check b.(ntrols c.(llrakes d.( fumit Controls I 4) „Se, CI 41 °dam- - e c„ s w �?-k x,714— vie lC�a � .. 7- `" # e 9V be,44r 71514 3. STRUCTURAL a.(-- ydraulics /Pneumatics b.( P'ns /Bolts /Keys c.(1Staactural Integrity d.(441 s/Wheels /Casters e.( arings /Spindles /Axles f. (#rrack/Rim Iron 6. OT ER a.( utomatic Sprinkler /Smoke Detector b.( ater Quality c.(4Bungy Cords d.(� ranes e.( Comments RESULTS: DACS -03419 Rev. 12/09 White /Bureau Canary / Owner or Manager Pink/Event Inspection _ of PURSUANT TO Section 616242(7), F.S., AN INSPECTION CERTIFICATE IS ISSUED, when box is checked. The above identified amusement ride meets the requirements of Section 616242, 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) # / . 0 7 "i acknowledge ride is §616242(16), and the receipt of this inspection report and the NOTICE OF RIGHTS on the reverse side of this form. I certify this amusement in compliance with §616.242, F.S. The employee responsible for operating this ride has been trained in accordance with F.S. and the manufacturers operating instructions or the operating fact sheets for this ride are available to the operator, last 14 daily inspection reports were completed and available upon request. Owner/Manager Signat Inspector's Signature ❑ PURSUANT TO Section 616.242(7), F.S., the above identified amusement ride does not meet the requirements of Section 616.242, F.S. and Chapter 5F-8, F.A.C. and shall not operate until it passes a subsequent inspection by the Department. STOP OPERATION ORDER (DACS 03545, Rev. 12/09) # Owner /Manager Signature Inspector's Signature DACS -03419 Rev. 12/09 White /Bureau Canary / Owner or Manager Pink/Event Inspection _ of Administrative Hearing Available If you wish to contest the Department's action, you have the right to request an administrative hearing to be conducted in accordance with Sections 120.569 and 120.57, Florida Statutes and to be represented by counsel or other qualified representative. Your request for hearing must contain: 1. Your name, address, and telephone number, and facsimile number (if any). 2. The name, address, and telephone number, and facsimile number of your attorney or qualified representative (if any) upon whom service of pleadings and other papers shall be made. 3. A statement that you are requesting an administrative hearing and dispute the material facts alleged by the department, in which case you must identify the material facts that are in dispute (formal hearing), or that you request an administrative hearing and that you do not dispute the facts alleged by the department (informal hearing). 4. A statement of when (date) you received this Notice and the file number of this Notice. Your request for a hearing must be received at the address shown on this Notice within twenty -one (21) days of receipt of this Notice. If you fail to obtain a Release from this Notice or fail to request an administrative hearing within the twenty -one (21) day deadline you waive your right to a hearing and the Department may enter a Final Order imposing up to the maximum penalties as authorized by Florida Law. have read this notice of rights: SIGNATURE OF OWNER DATE DACS -03419 Rev. 12/09 ADAM H. PUTNAM COMMISSIONER DATA: Date Inspector Event "sue r,1; Location Florida Department of Agriculture and Consumer Services • Division of 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: 1- 800 -435 -7352; Fax: (850) 921 -1539 FairRides @FreshFromFlorida.com Ride Owner KA OC e id MI (Wi1' =/ �3 Sal o — Unannounced Ride Name ` � i �, Re- inspection — Permit MFG e` 6 Inspection /Red Tag History Serial # empora , — Permanent USAID # Location When Facing: Permit # L. ./.20 Wirer R. ` ) KIDDIE NIE SUPER REQUIREMENTS: (Check each requirement as it is accomplished or place (N) if not applicable) 4L1,4-‘9 1. RIDE STATUS a.(Grp rmit b.(surance c.( ompliance/NDT d.(4- "Manuals 4. ATTACHMENTS a.( n Attachments b.( 4- c.( - traints d.(,- Sweeps DEFICIENCIES: 2. INSTALLATION a.( - cking b.('ncing /Guarding c.( races /Guys /Anchors d.( s e.( Electrical 5. OPERATION a.(M Check b.( 'Controls c.(4rakes d.( `� Limit Controls 3. STRUCTURAL a.( 1iydraulics /Pneumatics )`Pi b.( ns /Bolts /Keys. c.(l Stvuctural Integrity d.fires/W heels /Casters e.( rings /Spindles /Axles f. ( rack/Rim Iron 6.OTHER a.(7,-)//Automatic Sprinkler /Smoke Detector b.( ater Quality c.( B,ungy Cords d.(4tranes e.( Comments iv e 7` 075 d cte_ Aga 1 RESULTS: DACS;93419 Rev. 12/09 White /Bureau Canary/ Owner or Manager Pink/Event 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) # ‘ n 0 °'I 1 c I acknowledge ride is §616.242(16), and the receipt of this inspection report and the NOTICE OF RIGHTS on the reverse side of this form. 1 certify this amusement in compliance with §616.242, F.S. The employee responsible for operating this ride has been trained in accordance with F.S. and the manufacturers operating instructions or the operating fact sheets for this ride are available to the operator, last 14 daily inspfection reports were completed and available upon request. ,I (, Owner /Manager Signature Inspector's Signature ❑ PURSUANT TO Section 616242(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;93419 Rev. 12/09 White /Bureau Canary/ Owner or Manager Pink/Event Inspection _ of Administrative Hearing Available If you wish to contest the Department's action, you have the right to request an administrative hearing to be conducted in accordance with Sections 120.569 and 120.57, Florida Statutes and to be represented by counsel or other qualified representative. Your request for hearing must contain: 1. Your name, address, and telephone number, and facsimile number (if any). 2. The name, address, and telephone number, and facsimile number of your attorney or qualified representative (if any) upon whom service of pleadings and other papers shall be made. 3. A statement that you are requesting an administrative hearing and dispute the material facts alleged by the department, in which case you must identify the material facts that are in dispute (formal hearing), or that you request an administrative hearing and that you do not dispute the facts alleged by the department (informal hearing). 4. A statement of when (date) you received this Notice and the file number of this Notice. Your request for a hearing must be received at the address shown on this Notice within twenty -one (21) days of receipt of this Notice. If you fail to obtain a Release from this Notice or fail to request an administrative hearing within the twenty -one (21) day deadline you waive your right to a hearing and the Department may enter a Final Order imposing up to the maximum penalties as authorized by Florida Law. have read this notice of rights: SIGNATURE OF OWNER DATE DACS -03419 Rev. 12/09 ADAM H. PUTNAM COMMISSIONER Florida Department of Agriculture and Consumer Services Division of 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: 1- 800 - 435 -7352; Fax: (850) 921 -1539 FairRides@FreshFromFlorida.com DATA: Date fl- 4-4 1 Inspector `l l Event ') g O Location KIDDIE NON KIDDIE Ride Owner Ride Name MFG Serial # USAID # Permit # SUPER l c \\ avl \ Bf3Vi If i r Oro bed tea` c\ gib. Sc led — Unannounced Re- inspection - Permit Inspection /Red Tag History —" Te wpomry — Permanent Location When Facing: L. 5 ,� R. of REQUIREMENTS: (Check each requirement as it is accomplished or place (N) if not applicable) 1. RIDE STATUS a.(.- Permit b.( 4insurance c.( Compliance /NDT d.( Manuals 4. ATTACHMENTS a.( 4-Gen Attachments b (4 C;arriet/Tubs c (R estraints d.( Sweeps DEFICIENCIES: 2. INSTALLATION' a.(- 0Blocking 11(4Fencing /Guarding c.( 4 ,races /Guys /Anchors d.( 1Signs e.(`) Electrical 5. OPERATION a.(4f2PM Check b. (1' Controls c.( Brakes d.( Limit Controls A \o \c 3. STRUCTURAL, a.(, )1Hyrdraulics /Pneumatics b.G; Tips /Bolts /Keys c.(i Structural Integrity d.(41fires/Wheels /Casters e.(earings /Spindles /Axles f. (4-'frack/Rim Iron 6. OTHER a.(-4 utomatic Sprinkler /Smoke Detector b.(-<) /ater Quality c.(ungy Cords d.( Cranes e.(,Comments " V-NA\ RESULTS: DACS -03419 Rev. 12/09 White/Bureau Canary/ Owner or Manager Pink/Event 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 616242, 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) # f 5- g ,-1,-- 3 I acknowledge ride is §616242(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 §616242, F.S. The employee responsible for operating this ride has been trained in accordance with F.S. and the manufacturers operating instructions or the operating fact sheetTfoi7 this ride are available to the operator, last 14 daily inspection reports were completed and available 6'* icy r-6, ° . 9 ypyp,y�jP ®F j Owner /Manager Signature Inspector's Signature o PURSUANT TO Section 616242(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. 12/09 White/Bureau Canary/ Owner or Manager Pink/Event Inspection _ of Administrative Hearing Available If you wish to contest the Department's action, you have the right to request an administrative hearing to be conducted in accordance with Sections 120.569 and 120.57, Florida Statutes and to be represented by counsel or other qualified representative. Your request for hearing must contain: 1. Your name, address, and telephone number, and facsimile number (if any). 2. The name, address, and telephone number, and facsimile number of your attorney or qualified representative (if any) upon whom service of pleadings and other papers shall be made. 3. A statement that you are requesting an administrative hearing and dispute the material facts alleged by the department, in which case you must identify the material facts that are in dispute (formal hearing), or that you request an administrative hearing and that you do not dispute the facts alleged by the department (informal hearing). 4. A statement of when (date) you received this Notice and the file number of this Notice. Your request for a hearing must be received at the address shown on this Notice within twenty -one (21) days of receipt of this Notice. If you fail to obtain a Release from this Notice or fail to request an administrative hearing within the twenty -one (21) day deadline you waive your right to a hearing and the Department may enter a Final Order imposing up to the maximum penalties as authorized by Florida Law. I have read this notice of rights: SIGNATURE OF OWNER DATE DACS -03419 Rev. 12/09 ADAM H. PUTNAM COMMISSIONER DATA: Date Inspector Event Location Florida Department of Agriculture and Consumer Services Division of Consumer Services /Bureau of Fair Rides Inspection AMUSEMENT RIDE INSPECTION REPORT Section 616.242(4), Florida Statutes Rule 5F- 8.0012, Florida Administrative Code V V 0 USA 4 tet1S KIDDIE kfti al i I e IE Phone: 1- 800 -435 -7352; Fax: (850) 921 -1539 FairRides @FreshFromFlorida.com Ride Owner Mo4edriti / 'kl i'f V lu[ - Unannounced Ride Name a ) 0 6 C. Re- inspection — Permit MFG , 1/) C 0 Inspection /Red Tag History ' Serial # S FT S Lip I et ° S q )13 fliaorary - Permanent USAID # e ' 00 Location When Facing: Permit #i o L. R SUPER Roq ` cx. REQUIREMENTS: ,(Check each requirement as it is accomplished or place (N) if not applicable) 1. RIDE STATUS a.(4 rmit, b.( fsurance c.( rnpliance /NDT d.( Manuals 4. A ACHMENTS a.( /pen Attachments b.(4 arrier/Tubs c.( Restraints' d.( Sweeps DEFICIENCIES: 2. INS LATION a.( ocking b.(4 encing /Guarding c.(4Braces /Guys /Anchors d.(-1;5- e.(-Electrical 5. OP RATION a.(r PM Check b.( controls c.(�)Brakes' d.(imit Controls 0• 411 \ c)o k \coo c 6)-6) VcA,A,M 1 0„ RESULTS: �t 3. STRUCTURAL a.(J- ydraulics /Pneumatics b.O P' = s /Bolts /Keys c.yr-Structural Integrity d.( (rpres/Wheels /Casters e.(,) arings /Spindles /Axles f. (Ai-rack/Rim Iron 6. OT R a.( Automatic Sprinkler /Smoke Detector b.( 'Water Quality c.( ungy Cords d.( pr°anes e.(Comments q� DP FrA /Fr NQ Spur A kr V S Q Coal `"0- € "AEA\ s DACS -03419 Rev. 12/09 White /Bureau Canary/Owner or Manager Pink/Event 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 616242, F.S. and Chapter 5F -8, F:A.C. and the deficiencies noted above (if any) have been corrected. INSPECTION CERTFICATE (DACS 03550, Rev. 01/09) # ) s-O-7 9 0 I acknowledge ride is §616242(16), and the receipt of this inspection report and the NOTICE OF RIGHTS on the reverse side of this form. I certify this amusement in compliance with §616.242, F.S. The employee responsible for operating this ride has been trained in accordance with F.S. and the manufacturers operating instructions or the operating fact sheets for ride are available to the operator, last,14 daily inspection reports were completed and available upon request__--- Owner /Manager Signature Inspectors Signature o PURSUANT TO Section 616:242(7), FS., 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. 12/09 White /Bureau Canary/Owner or Manager Pink/Event Inspection of Administrative Hearing Available If you wish to contest the Department's action, you have the right to request an administrative hearing to be conducted in accordance with Sections 120.569 and 120.57, Florida Statutes and to be represented by counsel or other qualified representative. Your request for hearing must contain: 1. Your name, address, and telephone number, and facsimile number (if any). 2. The name, address, and telephone number, and facsimile number of your attorney or qualified representative (if any) upon whom service of pleadings and other papers shall be made. 3. A statement that you are requesting an administrative hearing and dispute the material facts alleged by the department, in which case you must identify the material facts that are in dispute (formal hearing), or that you request an administrative hearing and that you do not dispute the facts alleged by the department (informal hearing). 4. A statement of when (date) you received this Notice and the file number of this Notice. Your request for a hearing must be received at the address shown on this Notice within twenty -one (21) days of receipt of this Notice. If you fail to obtain a Release from this Notice or fail to request an administrative hearing within the twenty -one (21) day deadline you waive your right to a hearing and the Department may enter a Final Order imposing up to the maximum penalties as authorized by Florida Law. I have read this notice of rights: SIGNATURE OF OWNER DATE DACS -03419 Rev. 12/09 ADAM H. PUTNAM COMMISSIONER DATA: Date Inspector Event Location Florida. Department of Agriculture and Consumer Services Division of Consumer Services /Bureau of Fair Rides Inspection AMUSEMENT RIDE INSPECTION REPORT Section 616.242(4), Florida Statutes Rule 5F- 8.0012, Florida Administrative Code 1— ifs o3 DOSE MIA S" -8� Phone: 1- 800 -435- 7352; Fax: (850) 921 -1539 FairRides@FreshFromFlorida.com Ride Owner Ride Name MFG Serial # USAID # Permit # KIDDIE NON- KIDDIE WP REQUIREMENTS: (Check each requirement as it is accomplished or place (N) if not applicable) maetAl 4, fi4G/Fi C Cfc,-0177)/)% tulkee 1. 1 >(4oc L /Q(_ 00 Ali S"iedul - Unannounced Re- inspection - Permit Inspection /Red Tag History " e py - Permanent Location When Facing: L. Q i R. IA b 1.. RIDE STATUS a.(,'Permit b.(4lsurance c.( ', mpliance /NDT l Ma d.(nuals 4. ATTACHMENTS a.(Gen Attachments b.('Earrier/Tubs c.( 'Restraints d.( Sweeps DEFICIENCIES: 2. INSTALLATION a.( eking b.(ncing /Guarding c.( races /Guys /Anchors d.(agns e.( 'Electrical 5. OPERATION a.(�) M Check b.( controls c.( Brakes d.( 1-Limit Controls 0 Rko t":.. S Nor 3. STRUCTURAL a:( hydraulics /Pneumatics b.( Pins /Bolts /Keys c.(�f Structural Integrity d.( ( res/Wheels /Casters e.( wrings /Spindles /Axles f. (4 Track/Rim Iron 6 a.(4- ;, tomatic Sprinkler /Smoke Detector b.( ater Quality c.(-- -1,:tungy Cords d.(4Cfranes e. (: Comments r 1 r RESULTS: DACS,03419 Rev. 12/09 White/Bureau Canary/ Owner or Manager Pink/Event Inspection _ of PURSUANT TO Section 616242(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) # B S-0)-11 s, I acknowledge ride is §616242(16), and the receipt of this inspection report and the NOTICE OF RIGHTS on the reverse side of this form. I certify this amusement in compliance with §616.242, F.S. The employee responsible for operating this ride has been trained in accordance with F.S. and the manufacturers operating instructions or the operating fact sheets for this ride are available to the operator, last 14 daily inspection reports were completed and available upor�rgs= Owner /Manager Signature Inspector's Signature PURSUANT TO Section 616242(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 ins pection by the Department. STOP OPERATION ORDER (DACS 03545, Rev. 12/09) # .' Owner /Manager Signature Inspector's Signature DACS,03419 Rev. 12/09 White/Bureau Canary/ Owner or Manager Pink/Event Inspection _ of Administrative Hearing Available If you wish to contest the Department's action, you have the right to request an administrative hearing to be conducted in accordance with Sections 120.569 and 120.57, Florida Statutes and to be represented by counsel or other qualified representative. Your request for hearing must contain: 1. Your name, address, and telephone number, and facsimile number (if any). 2. The name, address, and telephone number, and facsimile number of your attorney or qualified representative (if any) upon whom service of pleadings and other papers shall be made. 3. A statement that you are requesting an administrative hearing and dispute the material facts alleged by the department, in which case you must identify the material facts that are in dispute (formal hearing), or that you request an administrative hearing and that you do not dispute the facts alleged by the department (informal hearing). 4. A statement of when (date) you received this Notice and the file number of this Notice. Your request for a hearing must be received at the address shown on this Notice within twenty -one (21) days of receipt of this Notice. If you fail to obtain a Release from this Notice or fail to request an administrative hearing within the twenty -one (21) day deadline you waive your right to a hearing and the Department may enter a Final Order imposing up to the maximum penalties as authorized by Florida Law. have read this notice of rights: SIGNATURE OF OWNER DATE DACS -03419 Rev. 12/09 ADAM H. PUTNAM COMMISSIONER Florida. Department of Agriculture and Consumer Services Division of 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: 1- 800 -435 -7352; Fax: (850) 921 -1539 FairRides@FreshFromFlorida.com DATA: Date ) 4- of -- / Is Ride Owner oh mi 14 I441 y Inspector ‘ p 'o J Ride Name a W 6 S Event S7- MFG iq A. - 1 A 7-0 7-0,-v.) Location Serial # `1 0-1 1 .S USAID # A 4-`3 Permit # 11 ti 0 Vi NON - KIDDIE SUPER ChY — Unannounced Re- inspection - Permit Inspection /Red Tag Historyr '- TemFry - Permanent Location When Facing: L. ®d' S R. REQUIREMENTS: (Check each requirement as it is accomplished or place (N) if not applicable) 1. RIDE STATUS a.( 0,ermit b.(`�surance c.( C mpliance /NDT d.(anuals 4. ATTACHMENTS a.( en Attachments b.(rrierITubs c.( straints; d.('Sweeps DEFICIENCIES: 2. INSTALLATION a.(41ocking b.(encing /Guarding c.( races /Guys /Anchors d.(T-S ns. e.(lectrical 5. OPERATION a.( A-44'- PM Check b.(Controls c.(,:r kes d.( tiimit Controls 3. ST13.1.ICTURAL a.(4Hydraulics/Pneumatics b.(jPins /Bolts /Keys c: (Sctu ra l Integrity d.( 1,)res/Wheels /Casters e.( 4/�arings /Spindles /Axles f. (4-Track/Rim Iron 6.OTHER a (4'Automatic Sprinkler /Smoke Detector b.(4 Water Quality c.(4 tangy Cords d.(4'Qranes e.( Comments RESULTS: DACS -03419 Rev. 12/09 White /Bureau Canary/ Owner or Manager Pink/Event 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) # f 7 T9 I acknowledge ride is §61 6242(16), and the receipt of this inspection report and the NOTICE OF RIGHTS on the reverse side of this form. I certify this amusement In compliance with §616.242, F.S. The employee responsible for operating this ride has been trained in accordance with F.S. and the manufacturers operating instructions or the operating fact sheets is ride are available to the operator, las 14 daily inspection reports were completed and available upo - a•. est 0)1 ( .) ?wet vi , lV Owner /Manager Signa't'ure Inspec'or's Signature PURSUANT TO Section 616:242(7), F.S., the above identified amusement ride does not meet the requirements of Section 616.242, F.S. and Chapter 5F- 8,F.A.C. and shall not operate until it passes a subsequent inspection by the Department. STOP OPERATION ORDER (DACS 03545, Rev. 12/09)# Owner /Manager Signature Inspector's Signature DACS -03419 Rev. 12/09 White /Bureau Canary/ Owner or Manager Pink/Event Inspection of Administrative Hearing Available If you wish to contest the Department's action, you have the right to request an administrative hearing to be conducted in accordance with Sections 120.569 and 120.57, Florida Statutes and to be represented by counsel or other qualified representative. Your request for hearing must contain: 1. Your name, address, and telephone number, and facsimile number (if any). 2. The name, address, and telephone number, and facsimile number of your attorney or qualified representative (if any) upon whom service of pleadings and other pagers 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. 12/09 ADAM H. PUTNAM COMMISSIONER DATA: Date Floridp Department of Agriculture and Consumer Services Division of Consumer Services /Bureau of Fair Rides Inspection AMUSEMENT RIDE INSPECTION REPORT Section 616.242(4), Florida Statutes Rule 5F- 8.0012, Florida Administrative Code ,71 t t� " h Inspector � Q Event. d . Location ;: KIDDIE NON- KIDDIE Phone: 1- 800 -435 -7352; Fax: (850) 921 -1539 FairRides @FreshFromFlorida.com Ride Owner 44404 er MI 4 t el (7/, Ride Name PO b.) 6_ MFG Serial # USAID # Permit # 010 r Oo"� L\ 0 ct cht-.ed — Unannounced Re-inspection — Permit Inspection /Red Tag History rripoay - Permanent Location Whqn Facing: L.Se r WV R. C.A, \ bi REQUIREMENTS: (Check each requirement as it is accomplished or place (N) if not applicable) 1. RID§ STATUS a.(1rnermit b (, urance c.( riipliance /NDT d.( 1 Manuals 4. ATTACHMENTS a.( n Attachments b:(' Carrier/Tubs c.( aints d.( Sweeps DEFICIENCIES: 2. INSTALLATION a.(4 ticking b.(4 F cing /Guarding c.( d.( e.( ces /Guys /Anchors Ins Electrical 5. OPERATION a.(,M Check b.( _Controls c.( (Braces d.( imit Controls. 3. STRUCTURAL a.(,lraulics /Pneumatics. b.( , PJrfs /Bolts /Keys c.(4SSructural Integrity d. (� 4-5ires/W heels /Casters e.(1- anngs /Spindles /Axles f. ( Jrack/Rim Iron 6. OT. R a.(c' tomatic Sprinkler /Smoke Detector b.(.4 ester Quality c.(-.ngy Cords d.(. +Canes e.(,-)/Comments 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) # tS 0 -- I acknowledge ride is §616242(16), and the receipt of this inspection report and the NOTICE OF RIGHTS on the reverse side of this form. I certify this amusement in compliance with §616.242, F.S. The employee responsible for operating this ride has been trained in accordance with F.S. and the manufacturers operating instructions or the operating fact sheets for this ride are available to the operator, lasj 14 daily inspection reports were completed and available upon. request. Owner /Manager Signatu e Inspect r's Signa ure ❑ PURSUANT TO Section 616242(7), FS., 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. 12/09 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. have read this notice of rights: SIGNATURE OF OWNER DATE DACS -03419 Rev. 12/09 ADAM H. PUTNAM COMMISSIONER Florida Department of Agriculture and Consumer Services Division of 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: 1- 800 -435 -7352; Fax: (850) 921 -1539 FairRides @FreshFromFlorida.com DATA Date 1 tI - I Ride Owner fp» L4I /4 yc tc nounced Inspector ( C 0 Ride Name 0, 0 `?eQ4 % eik r s Re- inspection — Permit ' Event 5 0��.E MFG ' A i`" p f Inspection /Red Tag History Location Serial # , fT R S 3917=`f 11 PDoi LT sprar�rl- Permanent USAID # 9 0 Location When Facing: Permit # [ I Li o- l s L•Gl w nr R. o v b NON- KIDDIE SUPER REQUIREMENTS: (Check each requirement as it is accomplished or place (N) if not applicable) 1. RIDE STATUS a.( perm0, b.( Osurance c.( cmpliance /NDT d.( s) Manuals 4. ATTACHMENTS a 9en Attachments b.(4Parrier/Tubs c.(�� f Restraints d.('Sweeps DEFICIENCIES: 2. INSTALLATION a.( Mocking b.(ncing /Guarding c.( 4 Braces /Guys /Anchors d.( Signs e.(< 'Electrical 5. OPERATION a.(PM Check b.(1. ntrols c.( jr-akes d.( I Limit Controls 3. STRUCTURAL a.(4)lydraulics /Pneumatics b.(4 ins /Bolts /Keys c.(c4St-ructural Integrity d.(%- ; res/Wheels/Casters_ e.() earings /Spindles /Axles f. (11- rack/Rim :Iron 6. OTHER a.( fj utomatic Sprinklerramoke Detector b.(,- ,ater Quality c.(,4ungy Cords d.(Cranes e.( `omments RESULTS: � s r 5 / PURSUANT TO Section 616242(7), F.S., AN INSPECTION CERTIFICATE IS ISSUED, when box is checked. The above identified amusement ride meets the requirements of Section 616242, 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) # 5-0 7 I acknowledge ride is §616242(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, FS. The employee responsible for operating this ride has been trained in accordance with F.S. and the manufacturers operating instructions or the operating fact sheetshis ride are available to the operator, last 14 daily inspection reports were completed and available upon st -----' ' '77—' 7 )/ 't Owner /Manager Signature Inspector's Signature o PURSUANT TO Section 616242(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 • DAC&03419 Rev. 12/09 White/Bureau Canary/ Owner or Manager Pink/Event. Inspection_ of Administrative Hearing Available If you wish to contest the Department's action, you have the right to request an administrative hearing to be conducted in accordance with Sections 120.569 and 120.57, Florida Statutes and to be represented by counsel or other qualified representative. Your request for hearing must contain: 1. Your name, address, and telephone number, and facsimile number (if any). 2. The name, address, and telephone number, and facsimile number of your attorney or qualified representative (if any) upon whom service of pleadings and other papers shall be made. 3. A statement that you are requesting an administrative hearing and dispute the material facts alleged by the department, in which case you must identify the material facts that are in dispute (formal hearing), or that you request an administrative hearing and that you do not dispute the facts alleged by the department (informal hearing). 4. A statement of when (date) you received this Notice and the file number of this Notice. Your request for a hearing must be received at the address shown on this Notice within twenty -one (21) days of receipt of this Notice. If you fail to obtain a Release from this Notice or fail to request an administrative hearing within the twenty -one (21) day deadline you waive your right to a hearing and the Department may enter a Final Order imposing up to the maximum penalties as authorized by Florida Law. I have read this notice of rights: SIGNATURE OF OWNER DATE DACS -03419 Rev. 12/09 Miami Shores Village Building Department 10050 N.E.2nd Avenue, Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 INSPECTION'S PHONE NUMBER: (305) 762.4949 FBC 20 ii i JAN 1 o BUILDING Permit No. MCI 1 �� PERMIT APPLICATION Master Permit No. Permit Type: MECHANICAL JOB ADDRESS: 418 NE 105 Street City: Miami Shores County: Miami Dade zip: 33162 Folio/Parcel #: Is the Building Historically Designated: Yes NO Flood Zone: OWNER: Name (Fee Simple Titleholder): Archdiocese of Miami Phone#: (305)727 -6243 Address: 9401 Biscayne Blvd. City: Miami Shores state: FL zip: 33138 Tenant/Lessee Name: St. Rose of Lima Catholic Church Phone#: (305)758 -0539 Email: CONTRACTOR: Company Name: Modem Midways, Inc. Phone#: (305) 234-7776 Address: 10420 SW 115 Street City: Miami state: FL zip: 33176 Qualifier Name: Brian L. Morrissey Phone#: (786) 586 -9568 State Certification or Registration #: Certificate of Competency #: Contact Phone#: (305) 234-7776 Email Address: bmorri9495 @aol.com DESIGNER: Architect/Engineer: Phone#: Value of Work for this Permit: $ 400.00 Square/Linear Footage of Work: Type of Work: °Address °Alteration °New URepair/Replace °Demolition Description of Work: Amusement rides for temporary Church Camival Jan. 25 -27 2013 ********* **** pax•*** ***** x *** *********** Fees******** **a **** ***+x****** ************ *+gym* *xis Submittal Fee $ Permit Fee $ £ ?O ► Q' CCF $ CO /CC $ Scanning Fee $ Radon Fee $ DBPR $ Bond $ Notary $ Training/Education Fee $ Technology Fee $ Double Fee $ Structural Review $ TOTAL FEE NOW DUE Bonding Company's Name (if applicable) Bonding Company's Address City State Zip Mortgage Lender's Name (if applicable) Mortgage Lender's Address City State Zip Application is hereby made to obtain a permit to do the work and installations as indicated. I certify that no work or installation has commenced prior to the issuance of a permit and that all work will be performed to meet the standards of all laws regulating construction in this jurisdiction. I understand that a separate permit must be secured for ELECTRICAL WORK, PLUMBING, SIGNS, WELLS, POOLS, FURNACES, BOIT.RRS, HEATERS, TANKS and AIR CONDITIONERS, ETC OWNER'S AFFIDAVIT: I certify that all the foregoing information is accurate and that all work will be done in compliance with all applicable laws regulating construction and zoning. "WARNING TO OWNER: YOUR FAILURE TO RECORD A NOTICE OF COMMENCEMENT MAY RESULT IN YOUR PAYING TWICE FOR IMPROVEMENTS TO YOUR PROPERTY. IF YOU INTEND TO OBTAIN FINANCING, CONSULT WITH YOUR LENDER OR AN ATTORNEY BEFORE RECORDING YOUR NOTICE OF COMMENCEMENT." Notice to Applicant: As a condition to the issuance of a building permit with an estimated value exceeding $2500, the applicant must promise in good faith that a copy of the notice of commencement and construction lien law brochure will be delivered to the person whose property is subject to attachment. Also, a certified copy of the recorded notice of commencement must be posted at the job site for the first inspection which occurs seven (7) days after the building permit is issued In the absence of such posted notice, the inspection will not be approved and a reinspection fee will be charged. Signature Owner or Agent The foregoing instrument was acknowl ged before me this y 20 by P1 ` I ► ° emvs Signature Contract .. The foregoing instrument was acknowledged before me this IA , day of . (I 1 (1 , 20, by bri omn heel Mo rr shy who is personally kn wn to me or who has produced DLit M(210 - o1a oTa identification and who did take an oath. 1f who is personally known to me or who has produced As identification and who did take an oath. NOTARY PUBLIC: Sign: Print: My Commission Expires: APPROVED BY HAVEZ URMAZA : Commission # EE 107733 •o Expires June 28, 2015 ;; '''' eondedmur "°yFai"emes -rope Examiner Structural Review Revised 3 /12/2012)(Revised 07 /10 /07)(Revised 06/10 /2009)(Revised 3/15/09) NOTARY PUBLIC: My Commission Expir DANILO CHAVEZ URMAZA j Commission # EE 107733 �. Expires June 28, 2015 ,Rrni� ° Bonded Thou Troy Fein Inswance 800 .985 -7018 *********** * ** ** **** *** * ** * Zoning Clerk ACCORD ® CERTIFICATE OF LIABILITY INSURANCE °01/02 2013 ' 01/02/2013 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 POLICIES 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 policyQes) 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 CONTACT Joanne Manion pN ONE FAX . No. Ext): 425 - 454 -3386 (A/C, No): 425- 451 -3716 E-MAIL ADDRESS: INSURER(S) APFORDING COVERAGE NAILS INSURER A: T.H.E. IMSUrance Company INSURED Briggs Transport, Inc. Modern Midways, Inc. 22901 Sherman Road Steger, IL 60475 INSURER B : 04/03/12 INSURERC. EACH OCCURRENCE INSURERD: DAMAGE PREMISES (Ea RENTED cuoccurrence) INSURERS: MED EXP (Any one person) INSURER F : COVERAGES CERTIFICATE NUMBER: 31234086 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS L TYPE OF INSURANCE INSR WVD POLICY NUMBER (MOUCM(D0JYYYY) (MMA POLICY LIMITS A GENERALLIABILIY X COMMERCIAL GENERAL LIABILITY CPP0100902 -02 04/03/12 04/03/13 EACH OCCURRENCE $ 1,000,000 DAMAGE PREMISES (Ea RENTED cuoccurrence) $ 5°0°°° MED EXP (Any one person) $ CLAIMS -MADE X OCCUR PERSONAL & ADV INJURY $ 1, 000, 000 GENERAL AGGREGATE $ 2,000,000 PRODUCTS - COMP /OP AGG $ 1, 000,000 GEN'L AGGREGATE POLICY LIMIT APPLIES PER JECOT fl LOC $ A AUrOMOBILELIABILIIY S ANY AUTO ALL OWNED AUTOS HIRED AUTOS B S SCHEDULED AUTOS NON-OWNED AUTOS CPP0100902 -02 04/03/12 04/03/13 COMBINED SINGLE LIMIT (Ea accident) $ 1,000,000 $ BODILY INJURY (Per person) BODILY INJURY (Per accident) $ PROPERTY DAMAGE (Per accident) $ $ A X UMBRELLALIAB EXCESS LIAB X OCCUR CLAIMS -MADE ELP0010210 -02 04/03/12 04/03/13 EACHOCCURRENCE $ 4,000,000 AGGREGATE $ 4,000,000 $ DED RETENTION $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUT VE OFFICERIMEMBER EXCLUDED? (Mandatory In NH) If yes, descrbe under DESCRIPTION OF OPERATIONS below Y / N N / A WC STATU- TORY LIMITS OTH- ER E.L EACH ACCIDENT $ E.L DISEASE - EA EMPLOYEE $ E.L DISEASE - POLICY LIMIT $ DESCRIPTION OF OPERATIONS 1 LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space Is required) The Archdiocese of Miami; Archbishop Thomas Wenaki; 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. CELLATION Village of Miami Shores c/o Building Dept. 10050 NE 2nd Avenue Miami Shores, FL 33138 I USA SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE //ter /1 1.9Y� 7 77 el ACORD 25 (2010/05) jomanion 31234086 ©1888 -2010 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD ACORDT, PRODUCER 203- 931 -7095 Specialty Insurance, LTD -Tom Plouffe P.O. Box 16901 West Haven, CT 06516 RAC DA 1( -M'°2 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 1 COMPANY B COMPANY C COMPANY D S THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE INDICATED, NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, BEEN REDUCED BY PAID CLAIMS. co LTR TYPE OF INSURANCE POLICY NUMBER PoucY EFFECTIVE DATE (MM/DD/YY) PDATE (MUMMY) EXPIRATION MM/DI D/YY)N LIMITS GENERAL UABILITY COMMERCIAL GENERAL LIABILITY PROT GENERAL AGGREGATE $ PRODUCTS - COMP/OP AGG $ CLAIMS MADE OCCUR PERSONAL & ADV INJURY $ OWNER'S & CONTRACTOR'S EACH OCCURRENCE $ FIRE DAMAGE (My one lire) $ MED EXP (Any one person) $ AUTOMOBILE LIABIUTY ANY AUTO ALL OWNED AUTOS SCHEDULED AUTOS HIRED AUTOS NON -OWNED AUTOS COMBINED SINGLE OMIT $ BODILY INJURY (Per person) $ BODILY INJURY (Per acddent) $ PROPERTY DAMAGE $ GARAGE UABILr1Y ANY AUTO AUTO ONLY - EA ACCIDENT $ OTHER THAN AUTO ONLY: EACH ACCIDENT $ AGGREGATE $ EXCESS UABILITY UMBRELLA FORM OTHER THAN UMBRELLA FORM EACH OCCURRENCE $ AGGREGATE $ $ A WORKERS COMPENSATION EMPLOYERS' LIABILITY THE PROPRIETOR/ PAR TNERSAD ECUTIVE OFFICERS ARE: AND INCL EXCL 28884960 IN 11 -1 -12 11 -1 -13 X TOR p� EL EACH ACCIDENT $ 1,000,000 X EL DISEASE - POLICY LIMIT $ 1 ,000,000 EL DISEASE - EA EMPLOYEE $ 1,000,000 OTHER DESCRIPTION OF OPERATIONS /LOCATIONSNEHICUES/SPECIAL ITEMS Archbishop of Miami, Archbishop Thomas Wenski, St. Rose of Lima Catholic Church & School, 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. CERT I AT HOLD .. , x.s.. 1 h>> Village of Miami Shores 10050 NE 2nd Avenue Miami Shores, FL 33138 CA I 1 SHOULD ANY EXPIRATION 10 DAYS I i OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE DATE THEREOF, THE ISSUING COMPANY WILL ENDEAVOR TO MAIL WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY UPON THE COMPANY, ITS AGENTS OR REPRESENTATIVES. BUT FAILURE OF ANY KIND AUTHORIZED REPRESENTATIVE Thomas Plouffe 3 S,tvi0 Miami Shores Village Building Department 90050 N.E.2nd Avenue, Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 INSPECTION'S PHONE NUMBER: (305) 762.4949 BUILDING PERMIT APPLICATION Permit Type: Electrical JOB ADDRESS: 418 NE 105th Street JA141 R Y• FBC 20 Permit No. C IV1O Master Permit No. MV 1. City: Miami Shores County: Miami Dade Zip: 33162 Folio/Parcel#: Is the Building Historically Designated: Yes NO Flood Zone: OWNER: Name (Fee Simple Titleholder): Archdiocese of Miami Phone#: (305) 727 -6241 Address: 9401 Biscayne Blvd. City: Miami Shores State: FL Tenant/Lessee Name: St. Rose of Lima Catholic Church Zip: 33138 Phu/let (305) 758 -0539 Email: CONTRACTOR: Company Name: Sun Power Electrical Co., Inc. Address: 1363 NE 182 Street City: North Miami Beach Qualifier Name: Silvio Medina State Certification or Registration #: EC13002897 Certificate of Competency #: Phone#: (305) 297 -6678 State: FL Zip: 33162 Phone#: (305) 297 -6678 Contact Phone#: (305) 297 -6678 Email Address: silviomedina @aol.com DESIGNER: Architect/Engineer: Phone#: Value of Work for this Permit: $ 400.00 Square/Linear Footage of Work: Type of Work: °Address °Alteration °New °Repair/Replace Description of Work: Temporary Church Carnival Jan. 25 -27 2013 °Demolition ******** * * * * * * * * * * * * * * * * * * * * * * * * * * * * * ** Fees************* * * * * * * * * * * * * * * * * * * * * * * * ** * * * * ** Submittal Fee $ Permit Fee $ �'�� P e) Scanning Fee $ Radon Fee $ Notary $ Training/Education Fee $ Double Fee $ Structural Review $ CCF $ CO /CC $ DBPR $ Bond $ Technology Fee $ TOTAL FEE NOW DUE $ •C Bonding Company's Name (if applicable) Bonding Company's Address City State Zip Mortgage Lender's Name (if applicable) Mortgage Lender's Address City State Zip Application is hereby made to obtain a permit to do the work and installations as indicated. I certify that no work or installation has commenced prior to the issuance of a permit and that all work will be performed to meet the standards of all laws regulating construction in this jurisdiction. I understand that a separate permit must be secured for ELECTRICAL WORK, PLUMBING, SIGNS, WELLS, POOLS, FURNACES, BOTT.F,RS, HEATERS, TANKS and AIR CONDITIONERS, ETC OWNER'S AFFIDAVIT: I certify that all the foregoing information is accurate and that all work will be done in compliance with all applicable laws regulating construction and zoning. "WARNING TO OWNER: YOUR FAILURE TO RECORD A NOTICE OF COMMENCEMENT MAY RESULT IN YOUR PAYING TWICE FOR IMPROVEMENTS TO YOUR PROPERTY. IF YOU INTEND TO OBTAIN FINANCING, CONSULT WITH YOUR LENDER OR AN ATTORNEY BEFORE RECORDING YOUR NOTICE OF COMMENCEMENT." Notice to Applicant: As a condition to the issuance of a building permit with an estimated value exceeding $2500, the applicant must promise in good faith that a copy of the notice of commencement and construction lien law brochure will be delivered to the person whose property is subject to attachment. Also, a certified copy of the recorded notice of commencement must be posted at the job site for the first inspection which occurs seven (7) days after the building permit is issued. In the absence of such posted notice, the inspection will not be approv and a reinspection fee will be charged. Signa Owner or Agent Signature Contractor The foregoing instrument was acknowlled ed before me this l/ The foregoing instrument was acknowledged before me this 4 20. P ,by t , `l'i 1 M,�°b4f1E , day of ' ,20J5,by known to me or who has produced As identification and who did take an oath. NOTARY PUBLIC: Sign: Print: o me or who has produced as identification and who did take an oath. NOTARY PUBLIC: — My Commission Expires: APPROVED B .60:11;;;;,,, DANILO CHAVEZ URWIA Commission # EE 107733 Expires June 28, 2015 800.385.7019 r??�- gad Thai Bonded Rift Insurance 'riAL' Plans Examiner Structural Review (Revised 3 /12/2012)(Revised 07110107)(Revised 06 /10/2009)(Revised 3115109) Sign: Print 7r My Commissio yiderr MARINO PASACfHE • MY COM MISS ION a EE53299 OF 0.`i �Er EXPIRES: •,1.91.-h 22. 2015 1400 -3- NOTARY Fl N) ul6cwm ein',�ic CO. ******* ********* ******** Zoning Clerk up CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 10/10/12 INSR 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 POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: lithe 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 Allstar Direct Insurance 16123 Biscayne Boulevard Aventura, FL 33160 Phone (305) 754-7414 Fax (305) 754-7416 CONTACT NAME: (,/CNN Ems: (305) 7547414 tam, A/No): (305) 7547416 ADDRESS: joe@allstardirectcom INSURER(S) AFFORDING COVERAGE NAIL # INSURER A: CYPRESS PROPERTY & CASUALTY GFL 1027371 00 81 INSURED Sun Power Electric Co Inc 1363 NE 182nd St North Miami Beach, FL 33162 -1333 (305) 297 -6678 INSURER B : EACH OCCURRENCE INSURER C: PR TO RENTED PREMISES (Ea occurrence) INSURER D : MED EXP (Any one person) INSURER E: PERSONAL & ADV INJURY INSURER F : ❑ COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. ILTR TYPE OF INSURANCE INSR WVD POLICY NUMBER (MM/UDDD/YYYFY) (MNWD/YYYY) LIMITS A GENERAL LIABILITY y COMMERCIAL GENERAL LIABILITY ❑ ❑ CLAMS -MADE V OCCUR ❑ Y Y GFL 1027371 00 81 09/25/2012 09/25/2013 EACH OCCURRENCE $ 1,000,000.00 PR TO RENTED PREMISES (Ea occurrence) $ 100 ,000.00 MED EXP (Any one person) $ 5,000.00 PERSONAL & ADV INJURY $ 1,000,000.00 ❑ GENERAL AGGREGATE $ 2,000,000.00 GEN'L AGGREGATE LIMITAPPLES PER ❑ POLICY ❑ 5EC ❑ LOC PRODUCTS - COMP /OP AGG $ 2,000,000.00 $ AUTOMOBILE LIABILITY ❑ ANY AUTO ❑ AALLOOSWNED ❑ SCHEDULED NON -OWNED ❑ HIRED AUTOS ❑ AUTOS ❑ ❑ (Oa COMBINED LIMIT $ BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE (Per accident) $ UMBRELLA LIAR ❑ OCCUR ❑ ❑ EXCESS LIAR ❑ CLAIMS -MADE EACH OCCURRENCE $ AGGREGATE $ ❑ DED ❑ RETENTION $ $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y 1 N ANY PROPRIETOR/PARTNER/EXECUTIVE N / A • 'CRY N IITS ❑ OT E.L EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? (Mandatory In NH) E.L DISEASE - EA EMPLOYE $ If yes describe under DESCRIPTION OF OPERATIONS below EL DISEASE - POLICY LIMIT $ DESCRIPTION OF OPERATIONS / LOCATIONS 1 VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) CERTIFICATE HOLDER CANCELLATION I MIAMI SHORES VILLAGE BUILDING DEPARTMENT 10050 Northeast 2nd Avenue Miami Shores, Florida 33138 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POUCY PROVISIONS. AUTHORIZED REPRESENTATNE "S C .r ACORD 25 (2010/05) QF ©1988 -2010 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD THIS IS NOT A BILL — DO NOT PAY 651340 -3 BUSINESS NAME 1 LOCATION SUN POWER ELECTRIC CO INC 1363 NE 182 ST 33162 NORTH MIAMI BEACH FIRST -CLAS; U.S. POSTAGI PAID MIAMI, FL PERMIT NO. 21 RENEWAL RECEIPT NO. 678368 -3 STATE# EC13002897 OWNER SUN POWER ELECTRIC CO INC Sec. Type of BusInese WORKER /S 196 ELECTRICAL CONTRACTOR 1 THIS IS ONLY A LOCAL BUSINESS TAX RECEIPT. IT DOES NOT PERMIT THE HOLDER TO VIOLATE ANY EXISTING REGULATORY OR ZONING LAWS OF THE COUNTY OR CITIES. NOR .DOES IT EXEMPT THE HOLDER FROM ANY OTHER PERMIT OR LICENSE REQUIRED BY LAW. THIS I9 NOT A CER 1FICATION OF THE HOLDER'S QUALIFICA- TIONS. PAYMENT RECEIVED MIAMI -DADE COUNTY TAX COLLECTOR: 09/07/2012 09010105001 000045.00 SEE OTHER SIDE DO NOT FORWARD SUN POWER ELECTRIC CO INC SILVIO J MEDINA PRES 1363 NE 182 ST N MIAMI BCH FL 33162 i1dhUnIIIIndhtl I'3lIldhdhlInIldlidhl/IlahCl STS TE ItF FL DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION ELECTRICAL CONTRACTORS LICENSING BOARD (850) 487 -1395 1940 NORTH MONROE STREET TALLAHASSEE FL 32399 -0783 MEDINA, SILVIO J SUN POWER ELECTRIC CO INC 1363 NE 182ND ST NORTH MIAMI BEACH FL 33162 Congratulations! With this license you become one of the nearly one million Floridians licensed by the Department of Business and Professional Regulation. Our professionals and businesses range from architects to yacht brokers, from boxers to barbeque restaurants, and they keep Florida's economy strong. Every day we work to improve the way we do business in order to serve you bette For information about our services, please log onto www.myfloridalicense.com. There you can find more information about our divisions and the regulations that impact you, subscribe to department newsletters and Team more about the Department's initiatives. Our mission at the Department is: License Efficiently, Regulate Fairly. We constantly strive to serve you better so that you can serve your customers. Thank you for doing business in Florida, and congratulations on your new license! DETACH HERE TAlS gale HAS for ED.B CGROU D :6kTE O FORA . AC ' 6.25 2 56, 2 DEPAR.TNSEN' OF BUS$N'ESS • PROrFES$$-IONAL RBGTTLATIO EC13002891-" 2 128021462 ERTIFIED ELECT ICAL CONTRACTOR INA; :aiLSTfiQ� �' �` SUN POWER. 'ELECTRIC CO /INC • IS CERTIFIED under the p=ovisious o€ ch. 489 F8. 8a#ix4tioa dat=AIIq 31r- aa14 Y,120822O3.Q07 9 I TINE • Lf (y, ' -TigvgD m_?' STATE OF FLORIDA DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION ETiECTR.ICAL ;Cc) FACTORS LICEIIsTWk BOARD x,12082203007 The : ELECTRICAL CO N.a`med; below S CE TI Under the provisions Expiration date: AUG 'CIO IED. of 'Chapter 489 31, 2014 DINA., S3 LYCS' J SUN 150'[4TER ELECTRIC :CO INC 13 63 11E 182ND ST NQR; .'H BEACH FL; 3.3162. DISPLAY AS REQUIRED BY LAW KEN LAWSON SECRETARY DATE, BATCH NUMBERS LICENSE NBR, 0 2 1: 802 462. EC1300201 The : ELECTRICAL CO N.a`med; below S CE TI Under the provisions Expiration date: AUG 'CIO IED. of 'Chapter 489 31, 2014 DINA., S3 LYCS' J SUN 150'[4TER ELECTRIC :CO INC 13 63 11E 182ND ST NQR; .'H BEACH FL; 3.3162. DISPLAY AS REQUIRED BY LAW KEN LAWSON SECRETARY JEFF ATWATER CHIEF FINANCIAL OFFICER a� nrs STATE OF FLORIDA DEPARTMENT OF FINANCIAL SERVICES DIVISION OF WORKERS' COMPENSATION * * CERTIFICATE OF ELECTION TO BE EXEMPT FROM FLORIDA WORKERS' COMPENSATION LAW * CONSTRUCTION INDUSTRY EXEMPTION 07 -29 -2011 This certifies that the individual listed below has elected to be exempt from Florida Workers' Compensation law. EFFECTIVE DATE: PERSON: FEIN: 10/15/2011 EXPIRATION DATE 10/14/2013 MEDINA SILVIO J 943472315 BUSINESS NAME AND ADDRESS: SUN POWER ELECTRIC CO INC 1363 NE 182ND STREET N MIAMI BEACH FL 33162 SCOPES OF BUSINESS OR TRADE: 1- FIRE ALARM CONTRACTOR 3- CERTIFIED ELECTRICAL CONTRACTO 2- SOLAR ENERGY SERVICE 4- TELEPHONE INSTALLATION * IMPORTANT: Pursuant to Chapter 440 . 05(14), F.S., an officer of a corporation who elects exemption from this chapter by filing a certificate of election under this section may not recover benefits or compensation under this chapter. Pursuant to Chapter 440.05(12), F.S., Certificates of election to be exempt... apply only within the scope of the business or trade listed on the notice of election to be exempt. Pursuant to Chapter 440.05(13), F.S., Notices of election to be exempt and certificates of election to be exempt shall be subject to revocation if, at any time after the Filing of the notice or the Issuance of the certificate, the person named on the notice or certificate no longer meets the requirements of this section for Issuance of a certificate. The department shall revoke a certificate at any time for failure of the person named on the certificate to meet the requirements of this section. QUESTIONS? (850) 413 -1809 OWC-252 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 01 -11 PLEASE CUT OUT THE CARD BELOW AND RETAIN FOR FUTURE REFERENCE STATE OF FLORIDA DEPARTMENT OF FINANCIAL SERVICES DIVISION OF WORKERS' COMPENSATION CONSTRUCTION INDUSTRY CERTIFICATE OF ELECTION TO BE EXEMPT FROM FLORIDA WORKERS' COMPENSATION LAW EFFECTIVE: 10/15/2011 EXPIRATION DATE: PERSON: SILVIO J MEDINA FEIN: 943472315 BUSINESS NAME AND ADDRESS: SUN POWER ELECTRIC CO INC 1383 NE 182ND STREET N MIAMI BEACH, FL 33162 10/14/2013 SCOPE OF BUSINESS OR TRADE 1- FIRE ALARM CONTRACTOR 2- SOLAR ENERGY SERVICE 3- CERTIFIED ELECTRICAL CONTRACTO 4- TELEPHONE INSTALLATION IMPORTANT ® Pursuant to Chapter 440.05(14), F.S., an officer of a corporation who elects exemption from this chapter by filing a certificate of election L under this section may not recover benefits or compensation under this D chapter. Pursuant to Chapter 440.05(12), F.S., Certificates of election to be H exempt.. apply only within the scope of the business or trade listed on the notice of election to be exempt E Pursuant to Chapter 440.05(13), F.S., Notices of election to be exempt and certificates of election to be exempt shall be subject to revocation if, at any time after the filing of the notice or the issuance of the certificate, the person named on the notice or certificate no longer meets the requirements of this section for issuance of a certificate. The department shall revoke a certificate at any time for failure of the person named on the certificate to meet the requirements of this section. QUESTIONS? (850) 413 -1609 CUT HERE * Carry bottom portion on the job, keep upper portion for your records. t1W0 =188 f litIEIDAti LECTIONI TO RE CROW REVISED 01 =11