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MC-15-94Inspection Worksheet Miami Shores Village �. 10050 N.E. 2nd Avenue Miami Shores, FL Phone: (305)795-2204 Fax: (305)756-8972 inspection Number: INSP-226578 Permit Number: MC -1-15-94 Inspection Date: January 23, 2015 Permit Type: Mechanical - Commercial Inspector: Perez, JanPierre Inspection Type: Final Owner: CHURCH, ST ROSE OF LIMA CATHOLIC Work Classification: Addition/Alteration Job Address: 415 NE 105 Street Miami Shores, FL Phone Number (305)758-0539 Parcel Number 1122310430010 Project: <NONE> Contractor: MODERN MIDWAYS Phone: (305)234-7776 Buildina Denartment Comments AMUSEMENT RIDES FOR TEMPORARY CHURCH Infractio Passed Comments INSPECTOR COMMENTS False CARNIVAL L JAN23-25, 2015 Inspector Comments Passed ISA Failed El Correction Needed ❑ Re -Inspection ❑ Fee No Additional Inspections can be scheduled until re -inspection fee is paid. For Inspections please call: (305)762-4949 January 26, 2015 Page 1 of 1 }, 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 5J-18.0012, Florida Administrative Code ADAM H. PUTNAM COMMISSIONER Phone 1-800-435-7352; Fax (850) 410-3797 FairRides@FreshFromFlorida.com DATA: PURSUANT TO Section 616.242(7), F.S., AN INSPECTION CERTIFICATE IS ISSUED, when box is checked. The above © Date O %- 1 -!-S Ride Owner Iu670164 ✓ -144 I-j Scheduled - Unannounced Inspector '✓� �� Ride Name 1-Z01.'to tit.., A Re -inspection - Permit Event J �> c_, ' "'� MFG Z 4. Inspection/Red Tag History Location cLonE-✓ Serial # Temporary- Permanent 616.242, F.S. and Rule Chapter 5J-18, F.A.C. and shall not operate until it passes a subsequent inspection by the Department. USAID # i9 Location When Facing: Owner/Manager Signature Inspector's Signature Permit # �r"-O 9e` L. jD R• �j/f L -- KIDDIE NON -KIDDIE SUPER REQUIREMENTS: (Check each requirement as it is accomplished or place (N) if not applicable) 1. RIDE STATUS 2. INSTALLATION 3. STRUCTURAL a.( ) Permit a.( ) Blocking a.( ) Hydraulics/Pneumatics b.( ) Insurance b.( ) Fencing/Guarding b.(4'Pins/Bolts/Keys c.( ) Compliance/NDT c.( ) Braces/Guys/Anchors c.( -'Structural Integrity d.( ) Manuals d.( -f Igns e.( Electrical d.(s` Tires/Wheels/Casters e.(,YBearings/Spindles/Axles f. (/,Track/Rim Iron 4. ATTACHMENTS 5. OPERATION 6. OTHER a.( TGen Attachments a.( ) RPM Check a.(A_'vAutomatic Sprinkler/Smoke Detector b.( ) Carrier/Tubs b.( ) Controls b.(4Water Quality c.( ) Restraints c.( ) Brakes c.(,} Bungy Cords d.( ) Sweeps d.( ) Limit Controls d.(j Cranes e.(-) Comments DEFICIENCIES: RESULTS: FDACS-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 Rule Chapter 5J-18, F.A.C. and the deficiencies noted above (if any) have been corrected. INSPECTION CERTFICATE (FDACS 03550, Rev. 01/09) #7,. / 6 1 acknowledge receipt of this inspection report and the NOTICE OF RIGHTS on the reverse side of this form. I certify this amusement ride is in compliance with Section 616.242, F.S. The employee responsible for operating this ride has been trained in accordance with Section 616.242(16), F.S. and the manufacturers operating instructions or the operating fact sheets for this ride are available to the operator, and the last 14 daily inspection reports were completed and available upon request. ,> 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 Rule Chapter 5J-18, F.A.C. and shall not operate until it passes a subsequent inspection by the Department. STOP OPERATION ORDER (FDACS 03545, Rev. 12/09) # Owner/Manager Signature Inspector's Signature FDACS-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 FDACS-03419 Rev. 12/09 ��. Florida Department of Agriculture and Consumer Services J'✓�'., Division of Consumer Services/Bureau of Fair Rides Inspection AMUSEMENT RIDE INSPECTION REPORT Section 616.242(4), Florida Statutes Rule 5J-18.0012, Florida Administrative Code ADAM H. PUTNAM COMMISSIONER Phone 1-800-435-7352; Fax (850) 410-3797 FairRides@FreshFromFlorida.com DATA: Date v # - y -6-- -- ' Ride Owner /'7077Cstg✓ M►-bpiay ens Scheduled -Unannounced Inspector Jn►d Ride Name / Its t t rv'tG` S`� ` Re -inspection - Permit Event / �.j � "''Q MFG AA Inspection/Red Tag History Location '` "�'N' $"�'�� Serial # �" �' Temporary - Permanent USAID # 4. es Location When Facing- acingPermit 616.242, F.S. and Rule Chapter 5J-18, F.A.C. and shall not operate until it passes a subsequent inspection by the Department. Permit# fir/ L. R. KIDDIE NON -KIDDIE SUPER REQUIREMENTS: (Check each requirement as it is accomplished or place (N) if not applicable) 1. RIDE STATUS 2. INSTALLATION 3. STRUCTURAL a.( ) Permit a.( ) Blocking a.( ) Hydraulics/Pneumatics b.(.-) Insurance b.( ) Fencing/Guarding b.(-~)Pins/Bolts/Keys c.(- ) Compliance/NDT c.( ) Braces/Guys/Anchors c.( -'Structural Integrity d.( ) Manuals d.( ) Signs fl tTires/Wheels/Casters e.( ) Electrical e.(-•'jBearings/Spindles/Axles f. W Track/Rim Iron 4. ATTACHMENTS a.( ) Gen Attachments b.( ) Carrier/Tubs c.( ) Restraints d.( ) Sweeps DEFICIENCIES: r RESULTS: 5. OPERATION a.( ) RPM Check b.( ) Controls c.( ) Brakes d.( ) Limit Controls l--% a Ie A'- 41` p r►/ A& d 6. OTHER a.(4) Automatic Sprinkler/Smoke Detector b.(� Water Quality c.(.-) Bungy Cords d.(') Cranes e.( ) Comments i G u�'Y>G it -0('04 % 5' FDACS-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 Rule Chapter 5J-18, F.A.C. and the deficiencies noted above (if any) have been corrected. INSPECTION CERTFICATE (FDACS 03550, Rev. 01/09) # I acknowledge receipt of this inspection report and the NOTICE OF RIGHTS on the reverse side of this form. I certify this amusement ride is in compliance with Section 616.242, F.S. The employee responsible for operating this ride has been trained in accordance with Section 616.242(16), F.S. and the manufacturers operating instructions or the operating fact sheets for this ride are available to the operator, and thq`lasy14 daily inspection reports were completed and available upon request. // If 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 Rule Chapter 5J-18, F.A.C. and shall not operate until it passes a subsequent inspection by the Department. STOP OPERATION ORDER (FDACS 03545, Rev. 12/09) # Owner/Manager Signature Inspector's Signature FDACS-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 FDACS-03419 Rev. 12/09 DATE Florida Department of Agriculture and Consumer Services Division of Consumer Services/Bureau of Fair Rides Inspection 'J AMUSEMENT M NT RIDE INSPECTION REPORT Section 616.242(4), Florida Statutes Rule 5J-18.0012, Florida Administrative Code ADAM H. PUTNAM COMMISSIONER Phone 1-800-435-7352; Fax (850) 410-3797 FairRides@FreshFromFlorida.com DATA: Date "" g" 3L " r Ride Owner A40�,7c',4.so, Ivry -Scheduled — Unannounced Inspector r ie. Ride Name ��JT�n y G et 411-" f`` Re -inspection —Permit Event 12 e--4''""" MFG C:.~ �'/�A/ 44- Inspection/Red Tag History Location �``�"'" 14AV-107 Serial # ti /4- Temporary— Permanent USAID # 2 toelr 4j Location When Facing; Permit# Pf3o L. R.�vw.G¢- 616.242, F.S. and Rule Chapter 5J-18, F.A.C. and shall not operate until it passes a subsequent inspection by the Department. V�,; KIDDIE NON -KIDDIE SUPER REQUIREMENTS: (Check each requirement as it is accomplished or place (N) if not applicable) 1. RIDE STATUS 2. INSTALLATION 3. STRUCTURAL a.( ) Permit a.( ) Blocking a.(/) Hydraulics/Pneumatics b.( ) Insurance b.(,) Fencing/Guarding b.(,j_Pins/Bolts/Keys c.( ) Compliance/NDT c.(,� Braces/Guys/Anchors c.(Structural Integrity d.( ) Manuals d.( Oigns d.(Tires/Wheels/Casters e.(,,fElectrical e.(,� Bearings/Spindles/Axles f. (,) Track/Rim Iron 4. ATTACHMENTS a.( -j Gen Attachments b.( )'Carrier/Tubs c.( ) Restraints d.( ) Sweeps DEFICIENCIES: 'rly 5. OPERATION a.( ) RPM Check b.( ) Controls c.( ) Brakes d.( ) Limit Controls 6. OTHER a.( ) Automatic Sprinkler/Smoke Detector b.( g4 Water Quality c.(,,l Bungy Cords d.(-) Cranes e.(_) Comments /1/J C G rel •lr si1/!� r..( k. c Y O A-, ` T Q C oK- 0 "N e C •a A^ r C__ 0 2-- -r> a s ,* % ,vU y. .L,, c if i .t/ 4' PA6F'9.4- RESULTS: FDACS-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 Rule Chapter 5J-18, F.A.C. and the deficiencies noted above (if any) have been corrected. INSPECTION CERTFICATE (FDACS 03550, Rev. 01/09) # /V-/ I acknowledge receipt of this inspection report and the NOTICE OF RIGHTS on the reverse side of this form. I certify this amusement ride is in compliance with Section 616.242, F.S. The employee responsible for operating this ride has been trained in accordance with Section 616.242(16), F.S. and the manufacturers operating instructions or the operating fact sheets for this ride are available to the operator, and the last 14 dai inspection reports were completed and available upon request. Owner/Manager Signature '" Inspector's Signature PURSUANT TO Section 616.242(7), F.S., the above identified amusement ride does not meet the requirements of Section ❑ 616.242, F.S. and Rule Chapter 5J-18, F.A.C. and shall not operate until it passes a subsequent inspection by the Department. STOP OPERATION ORDER (FDACS 03545, Rev. 12/09) # Owner/Manager Signature Inspector's Signature FDACS-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 FDACS-03419 Rev. 12/09 DATE T { . 3. 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 5J-18.0012, Florida Administrative Code ADAM H. PUTNAM COMMISSIONER Phone 1-800-435-7352; Fax (850) 410-3797 FairRides@FreshFromFlorida.com DATA: Date 0 /-- 1 1 — 1 Ride Owner /� �� nC''''r '`� "� Scheduled — Unannounced Inspector Ride Name Re-inspection — Permit Event /2oJc . , v, MFG Fi�e/MrC Inspection/Red Tag History Location U,004C7 Serial # ��Q Temporary — Permanent USAID # Location When Facing: f PURSUANT TO Section 616.242(7), F.S., the above identified amusement ride does not meet the requirements of Section Permit # P9,} L. R. p W N KIDDIE NON -KIDDIE SUPER Owner/Manager Signature Inspector's Signature REQUIREMENTS: (Check each requirement as it is accomplished or place (N) if not applicable) 1. RIDE STATUS 2. INSTALLATION 3. STRUCTURAL a.( ) Permit a.( ) Blocking a.(--'Hydraulics/Pneumatics b.( ) Insurance b.( ) Fencing/Guarding b.('I Pins/Bolts/Keys c.( ) Compliance/NDT c.( ) Braces/Guys/Anchors c.( Structural Integrity d.( ) Manuals d.( ) Signs d.( ) Tires/Wheels/Casters e.( ) Electrical e.( ) Bearings/Spindles/Axles f. ( ) Track/Rim Iron 4. ATTACHMENTS a.( -)'Gen Attachments b.( ) Carrier/Tubs c.( ) Restraints d.( ) Sweeps 5. OPERATION a.( ) RPM Check b.( ) Controls c.( ) Brakes d.( ) Limit Controls 6. OTHER a.( ) Automatic Sprinkler/Smoke Detector b.( ) Water Quality c.( ) Bungy Cords d.(—) Cranes e.( Comments DEFICIENCIES: /_ - C t I e ? /1 n_ c -r e - ✓ ^ 4V N4 u tM 1.0 SGJ2 I .c04.Ir.?a I --14 ��- noted above (if any) have been corrected. INSPECTION CERTIFICATE (FDACS 03550, Rev. 01/09) # I acknowledge receipt of this inspection report and the NOTICE OF RIGHTS on the reverse side of this form. I certify this amusement ride is in compliance with Section 616.242, F.S. The employee responsible for operating this ride has been trained in accordance with Section 616.242(16), F.S. and the manufacturers operating instructions or the operating fact sheets for this ride are available to the operator, and the last 14 daily inspection reports were completed and available upon request. 0 RESULTS: FDACS-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 Rule Chapter 5J-18, F.A.C. and the deficiencies noted above (if any) have been corrected. INSPECTION CERTIFICATE (FDACS 03550, Rev. 01/09) # I acknowledge receipt of this inspection report and the NOTICE OF RIGHTS on the reverse side of this form. I certify this amusement ride is in compliance with Section 616.242, F.S. The employee responsible for operating this ride has been trained in accordance with Section 616.242(16), F.S. and the manufacturers operating instructions or the operating fact sheets for this ride are available to the operator, and the last 14 daily inspection reports were completed and available upon request. 0 Owner/Manager Signature 71 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 Rule Chapter 5J-18, F.A.C. and shall not operate until it passes a subsequent inspection by the Department. STOP OPERATION ORDER (FDACS 03545, Rev. 12/09) # Owner/Manager Signature Inspector's Signature FDACS-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: 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 FDACS-03419 Rev. 12/09 DATE Q�QPRTMENi OFS 9 G a �yoGGNSUM E0. 5F.¢,`�y,.. EV191 6 1 JA 161.1010 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 5J-18.0012, Florida Administrative Code Phone 1-800-435-7352; Fax (850) 410-3797 FairRides@FreshFromFlorida.com DATA: 6. OTHER a.( ) RPM Check Date O /- 2 L - /S" Ride Owner Scheduled - Unannounced Inspector (�'o vo Ride Name Re -inspection - Permit Event 7e G�M.� MFG 'Q • „ i Inspection/Red Tag History Location r l.!or.24 -r Serial # �'� Temporary- Permanent USAID # Location When Facing: Permit# L. R. R.G KIDDIE NON -KIDDIE SUPER REQUIREMENTS: (Check each requirement as it is accomplished or place (N) if not applicable) 1. RIDE STATUS 2. INSTALLATION 3. STRUCTURAL a.( ) Permit a.( ) Blocking a.( ) Hydraulics/Pneumatics b.( ) Insurance b., -j, Fencing/Guarding b.( ) Pins/Bolts/Keys c.( ) Compliance/NDT c.e j Braces/Guys/Anchors c.( ) Structural Integrity d.( ) Manuals d.(/�Signs d.( ) Tires/Wheels/Casters e.(/, rElectrical e.(/5 Bearings/Spindles/Axles f. (AfTrack/Rim Iron 4. ATTACHMENTS a.( ) Gen Attachments b.( ) Carrier/Tubs c.( ) Restraints d.( ) Sweeps DEFICIENCIES: RESULTS: 4-d 5. OPERATION 6. OTHER a.( ) RPM Check a.k,�Automatic Sprinkler/Smoke Detector b.( ) Controls b.(;�fWater Quality c.( ) Brakes c.( `) Bungy Cords d.( ) Limit Controls d.( ) Cranes Owner/Manager Signature Inspector's Signature e.( ) Comments 'A J �x.AV lI rim , ,, v,� Iz<►,�� FDACS-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 Rule Chapter 5J-18, F.A.C. and the deficiencies noted above (if any) have been corrected. INSPECTION CERTFICATE (FDACS 03550, Rev. 01/09) # I acknowledge receipt of this inspection report and the NOTICE OF RIGHTS on the reverse side of this form. I certify this amusement ride is in compliance with Section 616.242, F.S. The employee responsible for operating this ride has been trained in accordance with Section 616.242(1W F.S. and the manufacturers operating instructions or the operating fact sheets for this ride are available to the operator, and thefla14 daily inspection reports were completed and available upon request. Owner/Manager Signature Inspector's Signature PURSUANT TO Section 616.242(7), F.S., the above identified amusement ride does not meet the requirements of Section ❑ 616.242, F.S. and Rule Chapter 5J-18, F.A.C. and shall not operate until it passes a subsequent inspection by the Department. STOP OPERATION ORDER (FDACS 03545, Rev. 12/09) # Owner/Manager Signature Inspector's Signature FDACS-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 FDACS-03419 Rev. 12/09 IML11r% k DATA: Date L " Florida Department of Agriculture and Consumer Services �JUv� Division of Consumer Services/Bureau of Fair Rides Inspection 0 Re -inspection - Permit AMUSEMENT RIDE INSPECTION REPORT MFG r �4-'t -fC c'.7-'4- Inspection/Red Tag History Section 616.242(4), Florida Statutes Serial # r` �r Rule 5J-18.0012, Florida Administrative Code ADAM H. PUTNAM USAID # % 3 COMMISSIONER Phone 1-800-435-7352; Fax (850) 410-3797 Permit # FairRides@FreshFromFlorida.com DATA: Date L " Ride Owner /"C'7o` "'� ~�""� �`""%.-. Scheduled - Unannounced Inspector Ride Name 0 Re -inspection - Permit Event -'0% MFG r �4-'t -fC c'.7-'4- Inspection/Red Tag History Location '�'�'�'"�' %hen' Serial # r` �r Temporary- Permanent b.( ) Water Quality USAID # % 3 Location When Facing: c.( ) Brakes Permit # L. R. KIDDIE NON -KIDDIE SUPER d.( ) Cranes REQUIREMENTS: (Check each requirement as it is accomplished or place (N) if not applicable) 1. RIDE STATUS 2. INSTALLATION 3. STRUCTURAL a.( ) Permit a.( ) Blocking a.( ) Hydraulics/Pneumatics b.( ) Insurance b.( ) Fencing/Guarding b.( ) Pins/Bolts/Keys c.( ) Compliance/NDT c.( ) Braces/Guys/Anchors c.( ) Structural Integrity d.( ) Manuals d.( ) Signs d.( ) Tires/Wheels/Casters e.( ) Electrical e.( ) Bearings/Spindles/Axles f. ( ) Track/Rim Iron 4. ATTACHMENTS 5. OPERATION 6. OTHER a.( ) Gen Attachments a.( ) RPM Check a.( ) Automatic Sprinkler/Smoke Detector b.( ) Carrier/Tubs b.( ) Controls b.( ) Water Quality c.( ) Restraints c.( ) Brakes c.( ) Bungy Cords d.( ) Sweeps d.( ) Limit Controls d.( ) Cranes e.( ) Comments DEFICIENCIES: RESULTS: FDACS-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 F1 identified amusement ride meets the requirements of Section 616.242, F.S. and Rule Chapter 5J-18, F.A.C. and the def iencies noted above (if any) have been corrected. INSPECTION CERTFICATE (FDACS 03550, Rev. 01/09) # ll }"� `C I acknowledge receipt of this inspection report and the NOTICE OF RIGHTS on the reverse side of this form. I certify this amusement ride is in compliance with Section 616.242, F.S. The employee responsible for operating this ride has been trained in accordance with Section 616.242(16), F.S. and the manufacturers operating instructions or the operating fact sheets for this, ride are available to the operator, and the last 14 daily inspection reports were completed and available upon request. 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 Rule Chapter 5J-18, F.A.C. and shall not operate until it passes a subsequent inspection by the Department. STOP OPERATION ORDER (FDACS 03545, Rev. 12/09) # Owner/Manager Signature Inspector's Signature FDACS-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: 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 FDACS-03419 Rev. 12/09 I9L,10 ' Florida Department of Agriculture and Consumer Services Division of Consumer Services/Bureau of Fair Rides Inspection ) Controls AMUSEMENT RIDE INSPECTION REPORT ) Brakes Section 616.242(4), Florida Statutes ) Limit Controls Rule 5J-18.0012, Florida Administrative Code ADAM H. PUTNAM COMMISSIONER Phone 1-800-435-7352; Fax (850) 410-3797 PURSUANT TO Section 616.242(7), F.S., the above identified amusement ride does not meet the requirements of Section FairRides@FreshFromFlorida.com DATA: Date Q/- ZZ1 — 15 Ride Owner 4/ A-0 Scheduled - Unannounced Inspector Ride Name 7-1,L J'" 0 &vV 1',OP G ( Re -inspection - Permit Event L MFG Inspection/Red Tag History Location Serial # Temporary - Permanent USAID # C 7 -?.e 5' Location When Facing: Permit # 7l L. R. KIDDIE NON -KIDDIE SUPER r REQUIREMENTS: (Check each requirement as it is accomplished or place (N) if not applicable) 1. RIDE STATUS 2. INSTALLATION 3. STRUCTURAL a.( ermit a.( ) Blocking a.(-) Hydraulics/Pneumatics b.(,,,Insurance b.( )'Fencing/Guarding b.(-.-) Pins/Bolts/Keys c.(4Compliance/NDT c.( }'Braces/Guys/Anchors c.(,4 Structural Integrity d.(,-fManuals d.( ISigns d.(.- Tires/Wheels/Casters e.( rElectrical e.( � Bearings/Spindles/Axles f. ( ) Track/Rim Iron 4. ATTACHMENTS a.( ) Gen Attachments b.( ) Carrier/Tubs c.( ) Restraints d.( ) Sweeps DEFICIENCIES: r:31 n RESULTS: 5. OPERATION a.( ) RPM Check b.( ) Controls c.( ) Brakes d.( ) Limit Controls Ali t 6. OTHER a.( ) Automatic Sprinkler/Smoke Detector b.( ) Water Quality c.( ) Bungy Cords d.( ) Cranes e.( ) Comments FDACS-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 Rule Chapter 5J-18, F.A.C. and the deficiencies noted above (if any) have been corrected. INSPECTION CERTIFICATE (FDACS 03550, Rev. 01/09) # I acknowledge receipt of this inspection report and the NOTICE OF RIGHTS on the reverse side of this form. I certify this amusement ride is in compliance with Section 616.242, F.S. The employee responsible for operating this ride has been trained in accordance with Section 616.242(16), F.S. and the manufacturers operating instructions or the operating fact sheets for this ride are available to the operator, and the last 14 daily inspection reports were completed and available upon request. �% 1 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 Rule Chapter 5J-18, F.A.C. and shall not operate until it passes a subsequent inspection by the Department. STOP OPERATION ORDER (FDACS 03545, Rev. 12/09) # Owner/Manager Signature Inspector's Signature FDACS-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: 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 FDACS-03419 Rev. 12/09 DATE (r r� Florida Department of Agriculture and Consumer Services 7, wL Division of Consumer Services/Bureau of Fair Rides Inspection AMUSEMENT RIDE INSPECTION REPORT r Section 616.242(4), Florida Statutes Rule 5J-18.0012, Florida Administrative Code ADAM H. PUTNAM COMMISSIONER Phone 1-800-435-7352; Fax (850) 410-3797 FairRides@FreshFromFlorida.com DATA: Date /) /- -L- L. - / ` Ride Owner h'�3 1-050-r Scheduled - Unannounced Inspector �-9 V Ride Name a (� Re -inspection - Permit Event !z v _e'�e MFG TU 2 s Inspection/Red Tag History Location Serial # ti 14 Temporary - Permanent b.( USAID # i 'D Location When Facing: c.( Permit # L. R. KIDDIE NON -KIDDIE SUPER d.( REQUIREMENTS: (Check each requirement as it is accomplished or place (N) if not applicable) 1. RIDE STATUS 2. INSTALLATION 3. STRUCTURAL a.( ) Permit a.( ) Blocking a.( ) Hydraulics/Pneumatics b.( ) Insurance b.( ) Fencing/Guarding b.( ) Pins/Bolts/Keys c.( ) Compliance/NDT c.(- ) Braces/Guys/Anchors c.( jStructural Integrity d.( ) Manuals d.(.'Signs d.(,)eTires/Wheels/Casters e.( TElectrical e.(-�Bearings/Spindles/Axles f. (,}`Track/Rim Iron 4. ATTACHMENTS 5. OPERATION 6. OTHER a.( ) Gen Attachments a.( ) RPM Check a.( ) Automatic Sprinkler/Smoke Detector b.(, ) Carrier/Tubs b.( ) Controls b.( ) Water Quality c.(`) Restraints c.( ) Brakes c.( ) Bungy Cords d.( `) Sweeps d.( ) Limit Controls d.( ) Cranes e.( ) Comments DEFICIENCIES: RESULTS: FDACS-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 F1 identified amusement ride meets the requirements of Section 616.242, F.S. and Rule Chapter 5J-18, F.A.C. ar},d the deficiencies noted above (if any) have been corrected. INSPECTION CERTFICATE (FDACS 03550, Rev. 01/09) # "-,2 1 `• I acknowledge receipt of this inspection report and the NOTICE OF RIGHTS on the reverse side of this form. I certify this amusement ride is in compliance with Section 616.242, F.S. The employee responsible for operating this ride has been trained in accordance with Section 616.242(16), VS. -and the manufacturers operating instructions or the operating fact sheets for this ride are available to the operator, and the last 14 aily inspection reports were completed and available upon request. ./ Owner/Manager Signature Inspector's Signature PURSUANT TO Section 616.242(7), F.S., the above identified amusement ride does not meet the requirements of Section ❑ 616.242, F.S. and Rule Chapter 5J-18, F.A.C. and shall not operate until it passes a subsequent inspection by the Department. STOP OPERATION ORDER (FDACS 03545, Rev. 12/09) # Owner/Manager Signature Inspector's Signature FDACS-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 FDACS-03419 Rev. 12/09 DATE ADAM H. PUTNAM COMMISSIONER DATA: 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 5J-18.0012, Florida Administrative Code Phone 1-800-435-7352; Fax (850) 410-3797 FairRides@FreshFromFlorida.com Date D /- Z Z - Ride Owner A10 H ">01-4V Scheduled - Unannounced Inspector Ride Name 1-4 tcw R 7 6 Re -inspection - Permit Event MFG 14C2 ) Automatic Sprinkler/Smoke Detector Inspection/Red Tag History Location f "' A -f ' r Serial # Temporary - Permanent c.( USAID # i.-112_3 c.( 'jBrakes Location When Facing: J ) Bungy Cords Permit # f' ) Sweeps L. R. KIDDIE NON -KIDDIE SUPER REQUIREMENTS: (Check each requirement as it is accomplished or place (N) if not applicable) 1. RIDE STATUS 2. INSTALLATION 3. STRUCTURAL a.( ) Permit a.( ) Blocking a.( ) Hydraulics/Pneumatics b.( ) Insurance b.( ) Fencing/Guarding b.( ) Pins/Bolts/Keys c.( ) Compliance/NDT c.( ) Braces/Guys/Anchors c.( ) Structural Integrity d.( ) Manuals d.( ) Signs d.( ) Tires/Wheels/Casters e.( ) Electrical e.( ) Bearings/Spindles/Axles f. ( ) Track/Rim Iron 4. ATTACHMENTS 5. OPERATION 6. OTHER a.( ) Gen Attachments a.(,-I'RPM Check a.( ) Automatic Sprinkler/Smoke Detector b.( ) Carrier/Tubs b.(4Controls b.( ) Water Quality c.( ) Restraints c.( 'jBrakes c.( ) Bungy Cords d.( ) Sweeps d.( )Limit Controls d.( ) Cranes e.( ) Comments DEFICIENCIES: `�- '�'L � /14 !.(` `►--j .1 l . � 6" %� �.11ttd, �%'� . � �L/: �i /L t l/ c� f "�.J ra �i ,V 6 T .S CC 7- /044,01* 's- .7 > 7 -,'Al d f &A,/ 7 s 0).S r) -le )-Je n ,i OL 711 & V S" RESULTS: FDACS-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 Rule Chapter 5J-18, F.A.C. and the deficiencies noted above (if any) have been corrected. INSPECTION CERTIFICATE (FDACS 03550, Rev. 01/09) # I acknowledge receipt of this inspection report and the NOTICE OF RIGHTS on the reverse side of this form. I certify this amusement ride is in compliance with Section 616.242, F.S. The employee responsible for operating this ride has been trained in accordance with Section 616.242(16), F.S. and the manufacturers operating instructions or the operating fact sheets for this ride are available to the operator, and the last 14 daily inspection reports were completed and available upon request. 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 Rule Chapter 5J-18, F.A.C. and shall not operate until it passes a subsequent inspection by the Department. STOP OPERATION ORDER (FDACS 03545, Rev. 12/09) # Owner/Manager Signature Inspector's Signature FDACS-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: 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 FDACS-03419 Rev. 12/09 DATE ADAM H. PUTNAM COMMISSIONER DATA: 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 5J-18.0012, Florida Administrative Code Phone 1-800-435-7352; Fax (850) 410-3797 FairRides@FreshFromFlorida.com Date j— 2 Ride Owner a'o >0.,? Al A., Y Scheduled — Unannounced Inspectors R L'o Ride Name Re -inspection — Permit Event MFG Inspection/Red Tag History Location '� ' `` M s��7� Serial # Temporary — Permanent USAID # / {=`<' a Location When Facing: PURSUANT TO Section 616.242(7), F.S., the above identified amusement ride does not meet the requirements of Section Permit# L. R. KIDDIE NON -KIDDIE SUPER Owner/Manager Signature Inspector's Signature REQUIREMENTS: (Check each requirement as it is accomplished or place (N) if not applicable) 1. RIDE STATUS 2. INSTALLATION 3. STRUCTURAL a.( ) Permit a.( ) Blocking a.( ) Hydraulics/Pneumatics b.('') Insurance b.( ) Fencing/Guarding b.( ) Pins/Bolts/Keys c.(l Compliance/NDT c.( ) Braces/Guys/Anchors c.( ) Structural Integrity d.( ) Manuals d.( ) Signs d.(,Tires/Wheels/Casters e.( ) Electrical e.( Bearings/Spindles/Axles f. (&)Track/Rim Iron 4. ATTACHMENTS a.( ) Gen Attachments b.( ) Carrier/Tubs c.( ) Restraints d.( ) Sweeps 5. OPERATION a.( ) RPM Check b.( ) Controls c.( ) Brakes d.( ) Limit Controls 6. OTHER a.( ) Automatic Sprinkler/Smoke Detector b.( ) Water Quality c.( ) Bungy Cords d.( ) Cranes e.( ) Comments DEFICIENCIES: rl-�A-f7 v b SPR �c 5�I sv RESULTS: FDACS-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 Rule Chapter 5J-18, F.A.C. and the deficiencies noted above (if any) have been corrected. INSPECTION CERTFICATE (FDACS 03550, Rev. 01/09) # ; / e I acknowledge receipt of this inspection report and the NOTICE OF RIGHTS on the reverse side of this form. I certify this amusement ride is in compliance with Section 616.242, F.S. The employee responsible for operating this ride has been trained in accordance with Section 616.242(16), F.S. and the manufacturers operating instructions or the operating fact sheets for this ride are available to the operator, and t e lash 14 daily inspection reports were completed and available upon request. O er/Manager SignatureInspector'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 Rule Chapter 5J-18, F.A.C. and shall not operate until it passes a subsequent inspection by the Department. STOP OPERATION ORDER (FDACS 03545, Rev. 12/09) # Owner/Manager Signature Inspector's Signature FDACS-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 FDACS-03419 Rev. 12/09 DATE -= " 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 5J-18.0012, Florida Administrative Code ADAM H. PUTNAM COMMISSIONER Phone 1-800-435-7352; Fax (850) 410-3797 FairRides@FreshFromFlorida.com DATA: Date I '— - ►- - ' - Ride Owner Inspector rt. -If VJ Ride Name Event 2. INSTALLATION MFG Location °` `�`' " ' S�'�"'r' Serial # ) Hydraulics/Pneumatics b.( --j Insurance USAID # b.( ) Pins/Bolts/Keys Permit # 1-40 **r*w M>Z+�. �Y1 Scheduled - Unannounced 7c— x'46,0, � Re -inspection - Permit •r S 040W s? Inspection/Red Tag History ho� Temporary - Permanent !> 79ea Location When Facing: L. � R. KIDDIE NON -KIDDIE SUPER 7 identified amusement ride meets the requirements of Section 616.242, F.S. and Rule Chapter 5J-18, F.A.C. and the deficiencies REQUIREMENTS: (Check each requirement as it is accomplished or place (N) if not applicable) 1. RIDE STATUS 2. INSTALLATION 3. STRUCTURAL a.( ) Permit a.( ) Blocking a.( ) Hydraulics/Pneumatics b.( --j Insurance b.( )`Fencing/Guarding b.( ) Pins/Bolts/Keys c. ompliance/NDT c.( Braces/Guys/Anchors c.( ) Structural Integrity d. ) anuals d.( YSigns d.( ) Tires/Wheels/Casters e.( ) Electrical e.( ) Bearings/Spindles/Axles f. ( ) Track/Rim Iron 4. ATTACHMENTS 5. OPERATION 6. OTHER a.( ) Gen Attachments a.( ) RPM Check a.( ) Automatic Sprinkler/Smoke Detector b.( ) Carrier/Tubs b.( ) Controls b.( ) Water Quality c.( ) Restraints c.( Brakes c.(,..4 Bungy Cords d.( ) Sweeps d.( ,)'Limit Controls d.(,,.)...Cranes e.(,�Comments DEFICIENCIES: RESULTS: FDACS-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 7 identified amusement ride meets the requirements of Section 616.242, F.S. and Rule Chapter 5J-18, F.A.C. and the deficiencies noted above (if any) have been corrected. INSPECTION CERTIFICATE (FDACS 03550, Rev. 01/09) # - r7 I acknowledge receipt of this inspection report and the NOTICE OF RIGHTS on the reverse side of this form. I certify this amusement ride is in compliance with Section 616.242, F.S. The employee responsible for operating this ride has been trained in accordance with Section 616.242(16), F.S. and be manufacturers operating instructions or the operating fact sheets for this ride are available to the operator, and the last 14 daily inspection reports were completed and available upon request. (` "x Owner/Manager Signature I 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 Rule Chapter 5J-18, F.A.C. and shall not operate until it passes a subsequent inspection by the Department. STOP OPERATION ORDER (FDACS 03545, Rev. 12/09) # Owner/Manager Signature Inspector's Signature FDACS-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 FDACS-03419 Rev. 12/09 DATE 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 5J-18.0012, Florida Administrative Code ADAM H. PUTNAM COMMISSIONER Phone 1-800-435-7352; Fax (850) 410-3797 FairRides@FreshFromFlorida.com DATA: Date �' �' 1 ' ` Ride Owner A4,& ri' T�✓ "'""a� """ �'� Scheduled -Unannounced InspectorRide Name Re -inspection - Permit Event MFG �""�-�f''`^-s� Inspection/Red Tag History Location �`"� `'`' 1^ cs '.r o� Serial # Temporary - Permanent USAID # / f PLY Location When Facing: Permit # 00 4 L. " R. KIDDIE NON -KIDDIE SUPER REQUIREMENTS: (Check each requirement as it is accomplished or place (N) if not applicable) 1. RIDE STATUS 2. INSTALLATION 3. STRUCTURAL a.( yPermit a.( ) Blocking a.( ) Hydraulics/Pneumatics b.( ), Insurance b.( ) Fencing/Guarding b.( Pins/Bolts/Keys c.( ) Compliance/NDT c.( ) Braces/Guys/Anchors c.(�;Structural Integrity d.( ) Manuals d.( ) Signs d.(,-YTires/Wheels/Casters e.( ) Electrical e.(-jBearings/Spindles/Axles f. ( )Track/Rim Iron 4. ATTACHMENTS a.( ) Gen Attachments b.( ) Carrier/Tubs c.( ) Restraints d.( ) Sweeps DEFICIENCIES: RESULTS: 5. OPERATION a.( ) RPM Check b.( ) Controls c.( ) Brakes d.( ) Limit Controls 6. OTHER a.(:-) Automatic Sprinkler/Smoke Detector b.( -).,Water Quality c.(`,) Bungy Cords fl e) Cranes e.( +Comments FDACS-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 Rule Chapter 5J-18, F.A.C. and the deficiencies noted above (if any) have been corrected. INSPECTION CERTFICATE (FDACS 03550, Rev. 01/09) # / G 2- ` cL -_,- I I acknowledge receipt of this inspection report and the NOTICE OF RIGHTS on the reverse side of this form. I certify this amusement ride is in compliance with Section 616.242, F.S. The employee responsible for operating this ride has been trained in accordance with Section 616.242(16), F.S. and the�nanufacturers operating instructions or the operating fact sheets for this ride are available to the operator, and the last 14 daily igs�bction reports were completed and available upon request. r Owner/Manager Signature Inspector's Signature PURSUANT TO Section 616.242(7), F.S., the above identified amusement ride does not meet the requirements of Section ❑ 616.242, F.S. and Rule Chapter 5J-18, F.A.C. and shall not operate until it passes a subsequent inspection by the Department. STOP OPERATION ORDER (FDACS 03545, Rev. 12/09) # Owner/Manager Signature Inspector's Signature FDACS-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 FDACS-03419 Rev. 12/09 DATE DATA: Date 0 "-'j- t" Florida Department of Agriculture and Consumer Services Inspector Division of Consumer Services/Bureau of Fair Rides Inspection Re -inspection - Permit AMUSEMENT RIDE INSPECTION REPORT MFG u'�^�"t Section 616.242(4), Florida Statutes - Rule 5J-18.0012, Florida Administrative Code ADAM H. PUTNAM c.( ) Restraints COMMISSIONER Phone 1-800-435-7352; Fax (850) 410-3797 ) Bungy Cords FairRides@FreshFromFlorida.com DATA: Date 0 "-'j- t" Ride Owner A -44> A -f 1 -0L -+4'Y,,,.. Scheduled - Unannounced Inspector Ride Name s`' '� R �'� i4 Re -inspection - Permit Event MFG u'�^�"t Inspection/Red Tag History Location Serial # �`'�� Temporary - Permanent c.( ) Restraints USAID # G}✓��'�' Location When Facing: ) Bungy Cords Permit# �:!,fJ 4 L. ) j~�x. R. %j/a Mta KIDDIE NON -KIDDIE SUPER REQUIREMENTS: (Check each requirement as it is accomplished or place (N) if not applicable) 1. RIDE STATUS 2. INSTALLATION 3. STRUCTURAL a.( ) Permit a.( ) Blocking a.( ) Hydraulics/Pneumatics b.( ) Insurance b.( -)'Fencing/Guarding b.( ) Pins/Bolts/Keys c.( ) Compliance/NDT c.(,)'Braces/Guys/Anchors c.( ) Structural Integrity d.( ) Manuals d.( ) Signs d.( .) Tires/Wheels/Casters e.( Electrical e.('`'j'Bearings/Spindles/Axles f. ('Track/Rim Iron 4. ATTACHMENTS 5. OPERATION 6. OTHER a.( ) Gen Attachments a.( +RPM Check a.( ) Automatic Sprinkler/Smoke Detector b.( ) Carrier/Tubs b.(';-Kontrols b.( ) Water Quality c.( ) Restraints c.( ,3 -Brakes c.( ) Bungy Cords d.( ) Sweeps d.( ofLimit Controls d.( ) Cranes e.( ) Comments DEFICIENCIES: - 2- 6t h �, �- ✓ •t �.!'� � c � � ,�, �. �-7--� < s a ,6r� �. -r' r3 � L r .. � �- f v c�+.--�•: RESULTS: FDACS-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 F1 identified amusement ride meets the requirements of Section 616.242, F.S. and Rule Chapter 5J-18, F.A.C. and the deficiencies noted above (if any) have been corrected. INSPECTION CERTIFICATE (FDACS 03550, Rev. 01/09) # I acknowledge receipt of this inspection report and the NOTICE OF RIGHTS on the reverse side of this form. I certify this amusement ride is in compliance with Section 616.242, F.S. The employee responsible for operating this ride has been trained in accordance with Section 616.242(16), F.S. and the manufacturers operating instructions or the operating fact sheets for this ride are available to the operator, and the last 14 daily inspection reports were completed and available upon request. / 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 Rule Chapter 5J-18, F.A.C. and shall not operate until it passes a subsequent inspection by the Department. STOP OPERATION ORDER (FDACS 03545, Rev. 12/09) # Owner/Manager Signature Inspector's Signature FDACS-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: 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 FDACS-03419 Rev. 12/09 DATE ADAM H. PUTNAM COMMISSIONER DATA: 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 5J-18.0012, Florida Administrative Code Phone 1-800-435-7352; Fax (850) 410-3797 FairRides@FreshFromFlorida.com Date to �- 2 1- - 49 Ride Owner � �° �' `'t'� 't �� au, ems.. Scheduled - Unannounced Inspector IO Ride Name ei4I � c (jr,7^ Re -inspection - Permit Event MFG Inspection/Red Tag History Location f 'i'" S"" ` Serial # Temporary - Permanent USAID # % e Va Location When Facing: 616.242, F.S. and Rule Chapter 5J-18, F.A.C. and shall not operate until it passes a subsequent inspection by the Department. Permit #y -'r L. /c '� R. KIDDIE NON -KIDDIE SUPER REQUIREMENTS: (Check each requirement as it is accomplished or place (N) if not applicable) 1. RIDE STATUS 2. INSTALLATION 3. STRUCTURAL a.( ) Permit a.( ) Blocking a.(°'T Hydraulics/Pneumatics b.( ) Insurance b.(/T Fencing/Guarding b.(, ,}`Pins/Bolts/Keys c.( ) Compliance/NDT c.( YBraces/Guys/Anchors c.(,�,8tructural Integrity d.( ) Manuals d.( ) Signs d.(- }-Tires/Wheels/Casters e.(/A)J21ectrical e.( ) Bearings/Spindles/Axles f. ( ) Track/Rim Iron 4. ATTACHMENTS 5. OPERATION 6. OTHER a.( ) Gen Attachments a.(,} RPM Check a.( ) Automatic Sprinkler/Smoke Detector b.( ) Carrier/Tubs b.(%).2ontrols b.( ) Water Quality c.( ) Restraints c.( )Brakes c.( ) Bungy Cords d.(/,�Aweeps d.( ) Limit Controls d.(rj'Cranes e.(1 -Comments DEFICIENCIES: f, , r-�, f' f i �/ ( l� 4 vy %"w _e j e r- y q A / G I IV `% d � �j or 1 G is '1"1.k L- r4f i'! I" 1., a t M t� If A 7> 41) r &, 6 r,' T- d 7 TL ri'%� d RESULTS: FDACS-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 Rule Chapter 5J-18, F.A.C. and the deficiencies noted above (if any) have been corrected. INSPECTION CERTFICATE (FDACS 03550, Rev. 01/09) # I acknowledge receipt of this inspection report and the NOTICE OF RIGHTS on the reverse side of this form. I certify this amusement ride is in compliance with Section 616.242, F.S. The employee responsible for operating this ride has been trained in accordance with Section 616.242(16), F.S. and the manufacturers operating instructions or the operating fact sheets for this ride are available to the operator, and the Ast y4 daily inspecti n reports were completed and available upon request. Owner/Manager Signatur 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 Rule Chapter 5J-18, F.A.C. and shall not operate until it passes a subsequent inspection by the Department. STOP OPERATION ORDER (FDACS 03545, Rev. 12/09) # Owner/Manager Signature Inspector's Signature FDACS-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 FDACS-03419 Rev. 12/09 DATE Florida Department of Agriculture and Consumer Services '�I✓' Division of Consumer Services/Bureau of Fair Rides Inspection AMUSEMENT RIDE INSPECTION REPORT Section 616.242(4), Florida Statutes —" Rule 5J-18.0012, Florida Administrative Code ADAM H. PUTNAM COMMISSIONER Phone 1-800-435-7352; Fax (850) 410-3797 FairRides@FreshFromFlorida.com DATA: Date ' - �- �--- �Sr Ride Owner dam''"" H�/�K �`� Scheduled - Unannounced Inspector Ride Name "^6 S' A- etcle- Re -inspection - Permit Event MFG '"Q 2' Inspection/Red Tag History Location %4 A- Serial # Temporary - Permanent Owner/Manager Signature Inspector's Signature USAID # =a Location When Facing: ❑ Permit # eve y2�.p L. KIDDIE NON -KIDDIE SUPER REQUIREMENTS: (Check each requirement as it is accomplished or place (N) if not applicable) 1. RIDE STATUS 2. INSTALLATION 3. STRUCTURAL a.( ) Permit a.( ) Blocking a.( ) Hydraulics/Pneumatics b.( )Insurance b.(')Fencing/Guarding b.(�Pins/Bolts/Keys c.( ) Compliance/NDT c.( -yBraces/Guys/Anchors c.( ) Structural Integrity d.( ) Manuals d.( )-Signs d.(Irires/Wheels/Casters e.( :)-Electrical e.( f Bearings/Spindles/Axles f. ( -tfrack/Rim Iron WA*i_Td:hy�I_=1"Ih a.( ) Gen Attachments b.( ) Carrier/Tubs c.( ) Restraints d.( ) Sweeps DEFICIENCIES: RESULTS: 5. OPERATION a.( ) RPM Check b.( ) Controls c.( ) Brakes d.( ) Limit Controls 6. OTHER a.( ) Automatic Sprinkler/Smoke Detector b.( ) Water Quality c.( >) Bungy Cords d.(-) Cranes e.(4 Comments (, G u' j k'o,-76 o .-�/ _:' dr u / C'' , / 0) L 3 I- �' f S FDACS-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 Rule Chapter 5J-18, F.A.C. }d the deficiencies noted above (if any) have been corrected. INSPECTION CERTFICATE (FDACS 03550, Rev. 01/09) # r I acknowledge receipt of this inspection report and the NOTICE OF RIGHTS on the reverse side of this form. I certify this amusement ride is in compliance with Section 616.242, F.S. The employee responsible for operating this ride has been trained in accordance with Section 616.242(16), F.S. and the manufacturers operating instructions or the operating fact sheets for this ride are available to the operator, and the last 14 daily inspection reports were completed and available upon request. 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 Rule Chapter 5J-18, F.A.C. and shall not operate until it passes a subsequent inspection by the Department. STOP OPERATION ORDER (FDACS 03545, Rev. 12/09) # Owner/Manager Signature Inspector's Signature FDACS-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: 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 FDACS-03419 Rev. 12/09 1911190 R Florida Department of Agriculture and Consumer Services Division of Consumer Services/Bureau of Fair Rides Inspection AMUSEMENT RIDE INSPECTION REPORT s Section 616.242(4), Florida Statutes Rule 5J-18.0012, Florida Administrative Code ADAM H. PUTNAM COMMISSIONER Phone 1-800-435-7352; Fax (850) 410-3797 FairRides@FreshFromFlorida.com DATA: Date © /— a-') —' �' Ride Owner A-4 V Scheduled —Unannounced Inspector C �'J Ride Name .5"Gud- C,`" Re -inspection — Permit Event 12C"k. MFG .�''r ° � �"'�+ Section 616.242(16), F.S. and the manufacturers operating instructions or the operating fact sheets for this ride are available to the Inspection/Red Tag History Location °�''' �- '"'7�t< S Serial # Owner/Manager Signature - Inspector's Signature Temporary — Permanent PURSUANT TO Section 616.242(7), F.S., the above identified amusement ride does not meet the requirements of Section USAID # ox / 616.242, F.S. and Rule Chapter 5J-18, F.A.C. and shall not operate until it passes a subsequent inspection by the Department. Location When Facing: STOP OPERATION ORDER (FDACS 03545, Rev. 12/09) # Permit # ' L. R. KIDDIE NON -KIDDIE SUPER REQUIREMENTS: (Check each requirement as it is accomplished or place (N) if not applicable) 1. RIDE STATUS 2. INSTALLATION 3. STRUCTURAL a.( ) Permit a.( ) Blocking a.( ) Hydraulics/Pneumatics b.( ) Insurance b.( ) Fencing/Guarding b.( ) Pins/Bolts/Keys c.( ) Compliance/NDT c.( ) Braces/Guys/Anchors c.( ) Structural Integrity d.( ) Manuals d.( ) Signs d.( ) Tires/Wheels/Casters e.( ) Electrical e.( ) Bearings/Spindles/Axles f. ( ) Track/Rim Iron 4. ATTACHMENTS a.( ) Gen Attachments b.( ) Carrier/Tubs c.( ) Restraints d.( ) Sweeps DEFICIENCIES: F21 5. OPERATION a.( ) RPM Check b.( ) Controls c.( ) Brakes d.( ) Limit Controls ..V-41rJ,N 4 i s IV t, C F Y -*,f q.Q d t L - RESULTS: (s �5 6. OTHER a.( ) Automatic Sprinkler/Smoke Detector b.( ) Water Quality c.( ) Bungy Cords d.( ) Cranes e.( ) Comments FDACS-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 Rule Chapter 5J-18, F.A.C. and the deficiencies noted above (if any) have been corrected. INSPECTION CERTIFICATE (FDACS 03550, Rev. 01/09) # /1 :f /y I acknowledge receipt of this inspection report and the NOTICE OF RIGHTS on the reverse side of this form. I certify this amusement ride is in compliance with Section 616.242, F.S. The employee responsible for operating this ride has been trained in accordance with Section 616.242(16), F.S. and the manufacturers operating instructions or the operating fact sheets for this ride are available to the operator, and the last 14 daily inspection reports were completed and available upon request. f� 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 Rule Chapter 5J-18, F.A.C. and shall not operate until it passes a subsequent inspection by the Department. STOP OPERATION ORDER (FDACS 03545, Rev. 12/09) # Owner/Manager Signature Inspector's Signature FDACS-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 FDACS-03419 Rev. 12/09 DATE ADAM H. PUTNAM COMMISSIONER DATA: 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 5J-18.0012, Florida Administrative Code 'j Phone 1-800-435-7352; Fax (850) 410-3797 iv FairRides@FreshFromFlorida.com� Date 0 /_ )--X _i r- Ride Owner "Db?A.ti ''L4 a O' _ Scheduled - Unannounced Inspector e_0 f %--D Ride Name Ive C -le' Re -inspection - Permit Event 4,&X& .L'"+r' MFG �''�'"?`^ �^� Inspection/Red Tag History Location Serial # Temporary - Permanent USAID # / c� V-$- 7 Location When Facing: 616.242, F.S. and Rule Chapter 5J-18, F.A.C. and shall not operate until it passes a subsequent inspection by the Department. Permit # L. g'G .. , ?,� R. KIDDIE NON -KIDDIE SUPER REQUIREMENTS: (Check each requirement as it is accomplished or place (N) if not applicable) 1. RIDE STATUS 2. INSTALLATION 3. STRUCTURAL a.( ) Permit a.( ) Blocking a.(4Hydraulics/Pneumatics b.( ) Insurance b.( ) Fencing/Guarding b.(-�'Pins/Bolts/Keys c.( ) Compliance/NDT c.( ) Braces/Guys/Anchors c.( 4 -Structural Integrity d.( ) Manuals d.( ) Signs d.( Tires/Wheels/Casters e.( ) Electrical e.( ) Bearings/Spindles/Axles f. ( ) Track/Rim Iron 4. ATTACHMENTS 5. OPERATION 6. OTHER a.( ) Gen Attachments a.( ) RPM Check a.( ) Automatic Sprinkler/Smoke Detector b.( ) Carrier/Tubs b.( ) Controls b.( ) Water Quality c.( ) Restraints c.( ) Brakes c.( ) Bungy Cords d.( ) Sweeps d.( ) Limit Controls d.(-1 Cranes e.(ITComments DEFICIENCIES: RESULTS: FDACS-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 Rule Chapter 5J-18, F.A.C. nd the deficiencies noted above (if any) have been corrected. INSPECTION CERTIFICATE (FDACS 03550, Rev. 01/09) # l l I acknowledge receipt of this inspection report and the NOTICE OF RIGHTS on the reverse side of this form. I certify this amusement ride is in compliance with Section 616.242, F.S. The employee responsible for operating this ride has been trained in accordance with Section 616.242(16), F S. and the manufacturers operating instructions or the operating fact sheets for thi ride are available to the operator, and the las�4 daily inspection reports were completed and available upon request. 4 -� el 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 Rule Chapter 5J-18, F.A.C. and shall not operate until it passes a subsequent inspection by the Department. STOP OPERATION ORDER (FDACS 03545, Rev. 12/09) # Owner/Manager Signature Inspector's Signature FDACS-03419 Rev. 12/09 White/Bureau Canary/ Owner or Manager Pink/Event Inspection — of i U Administrative Hearin Available 9 If yo�Iwisfi�montest the Department's action, you have the right to request an administrative he4 n t� be conducted in accordance with Sections 120.569 and 120.57, Florida Statutes and- be represented by counsel or other qualified representative. Your request for hearing must contain: 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 FDACS-03419 Rev. 12/09 DATE tt� j ti} i. 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 BUILDING PERMIT APPLICATION Permit Type: MECHANICAL FBC 20 I Permit No.A - /s-- f Master Permit No. JOBADDRESS: 415 NE 105th Street City: Miami Shores County: Miami Dade - Zip: - 33138 Folio/Parcel# Is the Building Historically Designated: Yes NO Flood Zone: OWNER: Name (Fee Simple Titleholder): Archdiocese of Miami Phone#: ( 305) 757-6241 Address: 9401 Biscayne Blvd City: Miami Shores State: FL Zip. 33138 Tenant/LesseeName: St. Rose of Lima- Catholic Church Phone#: ( 305) 758-9563 Email: CONTRACTOR: Company Name: Modern Midways, Inc Phone#.- (305)2134-7776 Address: 10420 SW 115 Street City: Miami State: FL Zip: 33176 Qualifier Name: Brian Morrissey Phone#: (3,)5) 234-7776 State Certification or Registration #: Certificate of Competency #: CN -31 0 Contact Phone#: (305)234=7776 Email Address: bmorri9495@aol.com DESIGNER: Architect/Engineer: Phone#: Value of Work for this Permit: $ $500 Square/Linear Footage of Work: Type of Work: ❑Address ❑Alteration ONew ❑Repair/Replace ❑Demolition Description of Work: Amusement- Rides for temporary Church Carnival Jan. 23-25, 2015 Submittal Fee $ Permit Fee $ CCF $ CO/CC $ Scanning Fee $ Radon Fee $ Notary $ Training/Education Fee $ Double Fee $ Structural Review $ DBPR $ Bond $ Technology Fee $ TOTAL FEE NOW DUE $ ` 3 Bonding Company's Name (if applicable) Bonding Company's Address City State Mortgage Lender's Name (if applicable) Mortgage Lender's Address City State Zip Zip Application is hereby made to obtain a permit to do the work and installations as indicated. I certify that no work or installation has commenced prior to the issuance of a permit and that all work will be performed to meet the standards of all laws regulating construction in this jurisdiction. I understand that a separate permit must be secured for ELECTRICAL WORK, PLUMBING, SIGNS, WELLS, POOLS, FURNACES, BOILERS, HEATERS, TANKS and AIR CONDITIONERS, ETC..... OWNER'S AFFIDAVIT: I certify that all the foregoing information is accurate and that all work will be done in compliance with all applicable laws regulating construction and zoning. "WARNING TO OWNER: YOUR FAILURE TO RECORD A NOTICE OF COMMENCEMENT MAY RESULT IN YOUR PAYING TWICE FOR IMPROVEMENTS TO YOUR PROPERTY. IF YOU INTEND TO OBTAIN FINANCING, CONSULT WITH YOUR LENDER OR AN ATTORNEY BEFORE RECORDING YOUR NOTICE OF COMMENCEMENT." Notice to Applicant: As a condition to the issuance of a building permit with an estimated value exceeding $2500, the applicant must promise in good faith that a copy of the notice of commencement and construction lien law brochure will be delivered to the person whose property is subject to attachment. Also, a 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 V `''� ' g Signature g Owner or Agent Contra4r The foregoing instrument was acknowledged before me this 7'' day ofi, 2U, by f&.. cure¢ i, who is personally known to me or who has produced P (_ As identification and who did take an oath. NOTARY PUBLIC: Sign: ll� Print: U✓t _ My Commission Expires: % t tFF05590 The foregoing instrument was acknowledged before me this ;-74 14 day of lbeele , 20,� by , who is personally known to me or who has produced_ �Ydrl�9ede9c�kntdedeieokdr&*9reY**�Y ie9e**etetet4e4c9e9: at4e �ket�:'lri: Jcdr*�edr9ei: iesBdrir3r�k9ede�Y9e�kde�k9t APPROVED BY '1 Plans Examiner Structural Review (Revised 3/12/2012XRevised 07/10/07)(Revised 06/10/2009)(Revised 3/15/09) as identification and who did take an oath. NOTARY PUBLIC: Sign: Print: My Commission MARINO PASE MY COMMISSION N X53299 tp� Z)ai rftl` s Msrch 22, 2015 Zoning Clerk Local Business Tax Receipt Miami—Dade County, State Of Florida THIS IS NOT A BILL —DO NOT PAY 2374551 BUSINESS NAPAWLOCATION MODERN MIDWAYS OUR LADY DVN PROV CATHOLIC CHURCH 10205 W FLAGLER ST MIAMI, FL 33174 OwNRR MODERN MIDWAYS units) 10 RECEIPT NO. RENEWAL 2494730 SEC. TYPE OF BUSINESS 191 CARNIVAL - SPONSORED LBT 1-1, i--/ EXPIRES SEPTEMBER 30, 2015 Must be displayed at place of business Pursuant to County Code Chapter BA - Art. 9 & 10 PAYMENT RECEIVED BY TAX COU.EGTOR 400.00 10/16/2014 0221-15,000284 This Laval Badness Tex ReceW oalp coldirwe popwat of tie Local business Tax. The Recut is to a ticanse, pare" OF a eertilioation of the holder's I,aalificatloos, to do hasisaft Halder must coatply wah a" er nangaijaranwalal tegoht" taros sad r"Wreavner wbich spar to dw baahress. Tia RECEIPT tom. above wast be displayed as all aoaaaaroial+rohftks- Miand 4ade Cada Sec Ba -21& ionFar 1110M iglotwatioo. VI* VAMMId" e -I ARCHDIOCESE OF MIAMI Building and Property Office July 7, 2014 Metropolitan Miami -Dade County Building Department To Whom It May Concern: The Archdiocese of Miami, as owner of St. Rose of Lima Property located at 415 NE 105`x' Street, Miami Shores does hereby grant permission for the parish to hold a carnival on site beginning January 23 to through January 25, 2015. Sincerely yours in Christ, Sister Elizabeth Worley, SSJ Chancellor of Administration & COO Archdiocese of Miami 9401 Biscayne Boulevard, Miami Shores, FL 33138 2015 /01 /15 13:14:5 5 2 /2 Ac".r>" CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) 1 15/2015 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 pollcy(les) 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 rthur J. Gallagher Risk Management Services, Inc. 108th Ave NE, #200 Bellevue WA 98004 CON NAME:lanion PHONE Fax - A/ No): - -3716 fAIC777 EMAIL ADDRESS: INSURER(S) AFFORDING COVERAGE NAIC $ INSURER A:T.H.E. Insurance Company 12866 INSURED BR IGTRA-01 Briggs Transport, Inc. Modern Midways, Inc. 22901 Sherman Road Steger, IL 60475 INSURER B: INSURER C: INSURER D: INSURER E INSURER F : COVERAGES CERTIFICATE NUMBER: 678568320 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. INSR TYPE OF INSURANCE POLICY UMBER POLICY EFF POLICY EXP LIMITS • GENERAL LIABILITY CPP010090204 /3/2014 /3/2015 EACH OCCURREN$1,000,000 CE -DAMAGE 10 PREMISES(Ea occurrence) $100,000 X COMMERCIAL GENERAL LIABILITY MED EXP (Any oneperson) $ CLAIMS -MADE F1 OCCUR PERSONAL & ADV INJURY $1,000,000 GENERAL AGGREGATE $2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $1 000 000 17 POLICY PRO- F1 LOC $ A AUTOMOBILE LIABILITYCPP010090204 /3/2014 /3/2015 Ea accident) 1,000,000 BODILY INJURY (Per person) $ ANY AUTO ALL OWNEDX SCHEDULED AUTOS AUTOS ( BODILY INJURY Per accident) $ X NOOWNED AUTOS X N -AUTOS PerOacodenDAMAGE $ HIRED $ UMBRELLA LIAB X OCCUR ELP001021005 /3/2014 SJ2015 EACH OCCURRENCE $4,000,000 X EXCESS LIAB CLAIMS -MADE AGGREGATE $4,000,000 DED I X I RETENTION$0 $ 1 WORKERS COMPENSATION_ AND EMPLOYERS' LIABILITY Y / H ANY PROPRIETOR/PARTNEPJEXECUTIVE OFFICER/MEMBER EXCLUDED? ❑ N / A C144670 10/29/2014 10/29/2015 X TWO STATU- OTH- E.L. EACH ACCIDENT $1,000,000 E.L. DISEASE -EA EMPLOYE $1,000,000 (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $1,0()0,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, If more space is required) St. Rose of Lima Catholic Church & School; The Archdiocese of Miami; Archbishop Thomas Wenski and Village of Miami Shores, Florida are included as additional insureds but only as respects the operation of the named insured per policy terms and conditions - policy form CG133C 07/95. Event Dates: January 23 - 25, 2015 Village of Miami Shores c/o Building Dept 10050 NE 2nd Avenue Miami Shores FL 33138 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 dw-e. ACORD CORPORATION. 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