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MC-16-26 3 26 Miami Shores Village M Peii It I�ype'Mechanical coil"Moicial ` �,. 10050 N.E.2nd Avenue NE n Work.Ctassi atiarx Additi,611jAlteration Miami Shores,FL 33138-0000 1,11 Me' Permit Status.`APP12U11ELy, Phone: (305)795-2204 Ft0Ri>ap 111�i6 ,_ Expiration: 07/09/2016 Project Address Parcel Number Applicant 415 NE 105 Street Number: CHURCH BLDG 1122310430010 Miami Shores, FL Block: Lot: ST ROSE OF LIMA CATHOLIC C Owner Information Address Phone Cell ST ROSE OF LIMA CATHOLIC CHURCH 9401 BISC BLVD (305)758-0539 MIAMI FL 33138-2970 J1 Contractor(s) Phone Cell Phone $ 500.00 Valuation: MODERN MIDWAYS (305)234-7776 _...._...._._ .. . ..... _ Total Sq Feet: 0 Tons: Available Inspections: Additional Info:AMUSEMENT RIDES FOR TEMPORARY CHURC Inspection Type: Classification:Commercial Ventilation Approved:In Review Final Comments: Date Approved::In Review Rough Date Denied: Type of Work: Rough Duct Scanning:3 Duct Detector Test Review Mechanical Fees Due Amount Pay Date Pay Type Amt Paid Amt Due CCF $0.60 DBPR Fee Invoice# MC-1-16-58245 $7.50 DCA Fee $7.50 01/11/2016 Check#:10421 $475.60 $50.00 Education Surcharge $0.20 01/07/2016 Check* 10411 $50.00 $0.00 Permit Fee $500.00 Scanning Fee $9.00 Technology Fee $0.80 Total: $525.60 In consideration of the issuance to me of this permit, I agree to perform the work covered hereunder in compliance with all ordinances and regulations pertaining thereto and in strict conformity with the plans,drawings, statements or specifications submitted to the proper authorities of Miami Shores Village. In accepting this permit I assume responsibility for all work done by either myself, my agent, servants, or employes. I understand that separate permits are required for ELECTRICAL,PLUMBING,MECHANICAL,WINDOWS,DOORS,ROOFING and SWIMMING POOL work. OWNERS 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 an0-foning. f uthe/more,I authorize the above-named contractor to do the work stated. V1�r January 11, 2016 Authorized Signature:OwQe3 / Applicant / Contractor / Agent Date Building Department Copy January 11,2016 1 NATIONAL ASSOCIATION OF aMs OFFICIALS RIDE SAFETY CERTIFIED Briar,Morrissey � LeisureTimeAssociate LEVEL II (Advia�) ExpiratNumber " CM- 310 0313`1120`16 AMUSEMI:NT RIDE W a ' INSPES ''OR p idem 0 Local Business Tax Receipt Miami-Dade County, State of Florida THIS IS NOT A 8ltl-00 NOT FAY L B T_� 6906151 BUSINESS NAMEILOCATION RECEIPT NO. EXPIRES MODERN MIDWAYS @ ST RENEWAL SEPTEMBER 30, 2016 JOACHIM 7182009 Muse be.displayed at place o6 business 19150 SW 117 AVE Pursuant to County Code MIAMI,FL 33177 Chapter BA-Are.9&10 OWNER SEC.TYPE OF allSINESS PAYMENT RECEIVED MODERN MIDWAYS 191 CARNIVAL- BY TAX COLLECTOR SPONSORED 400.00 11/12!2015 Unit(s) 10 0232-16-000262 This Local Business Tax Receipt anly confirms payment of the Local Business Tax.The Receipt is not a license, permit,ora certification of the holder's qualifications,to do business.Holder must comply with any governmental or nongovernmental regulatory laws and requirements which apply to the business. The RECEIPT N0.above must be displayed on all commercial vehicles-Miami-Dade Code Sec Its-276. M for more information,visit www roiamidedo.aov/iaxoollector CERTIFICATE OF LIABILITY INSURANCE 11/25/22015015DATE /yYY17 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(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 Ileu of such endorsemen s. PRODUCER CONTANAME:CT Joanne Manion Arthur J.Gallagher Risk Management Services,Inc. PHONE 42554-3386 FA't 425-451-3716 777 108th Ave NE,#200 E-MAIL Bellevue WA 98004 INSU S AFFORDING COVERAGE NAIC S INSURERA:T.H.E. Insurance Company 12866 INSURED BRIGTRA-01 INSURER B: Briggs Transport, Inc.Modem Midways, Inc. INSURERC: 22901 Sherman Road Steger,IL 60475 INSURER D INSURER E INSURER F: COVERAGES CERTIFICATE NUMBER:1207514239 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 ADDLISUBR POLICY EFF POLICY EXP TR TYPE OF INSURANCE INSD INVO POLICY NUMBER MID MMIW LIMITS A X COMMERCIAL GENERAL LIABILITY CPP010090205 4/3/2015 4/3/2016 EACH OCCURRENCE $1,000,000 D TO RENTED CLAIMS-MADEX❑OCCUR PREMISES Ea occurrence) $100,000 MED EXP(Any one person) $Excluded PERSONAL&ADV INJURY $1,000,000 GEML AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $2,000,000 POLICY El JE71 LOC PRODUCTS-COMP/OP AGG $1,000,000 OTHER: $ A AUTOMOBILE LIABILITY CPP010090206 4/3/2015 4/3/2016 Ea accidentNULL IT $1,000,000 ANY AUTO BODILY INJURY(Per person) $ ALL ED X SCHEDULED BODILY INJURY(Per accident) S X HIRED AUTOS X NON-OWNED PROPERTY DAMAGE $ AUTOS Per accident $ A UMBRELLA LAB X OCCUR ELP001021006 4/3/2015 4/3/2016 EACH OCCURRENCE $4,000,000 X EXCESS LIAB CLAIMS-MADE AGGREGATE $4,000,000 DED I X I RETENTION$0 $ A WORKERS COMPENSATION WCP0004670003 10/29/2015 10/29/2016 X AND EMPLOYERS'LIABILITY STATUTE E ANY PROPRIETORIPARTNEROMCUTIVE YIN N/A E.L.EACH ACCIDENT $1,000,000 OFFICERIMBdBER EXCLUDED? El (Mandatory in NH) E.L.DISEASE-EA EMPLOYE $1,000,000 It yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be akacked a 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 22-24,2016 CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Village of Miami Shores ACCORDANCE WITH THE POLICY PROVISIONS. cJo Building Dept 10050 NE 2nd Avenue AUTHORIZED REPRESENTATIVE Miami Shores FL 33138 USA ©198&2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD Y 1 Inspection Worksheet Miami Shores Village 10050 N.E. 2nd Avenue Miami Shores, FL Phone: (305)795-2204 Fax: (305)756-8972 nspection Number: INSP-250504 Permit Number: MC-1-16-26 Inspection Date: January 21, 2016 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 CHURCH BLDG Miami Shores, FL Phone Number (305)758-0539 Parcel Number 1122310430010 Project: <NONE> Contractor: MODERN MIDWAYS Phone: (305)234-7776 Building Department Comments AMUSEMENT RIDES FOR TEMPORARY CHURCH Infractio Passed Comments CARNIVAL(JAN 22-24, 2016) INSPECTOR COMMENTS False Inspector Comments Passed El Failed 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 25,2016 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 ' ADAM H.PUTNAM Rule 5J-18.0012,Florida Administrative Code COMMISSIONER Phone 1-800-435-7352; Fax(850)410-3797 FairRides@FreshFromFlorida.com DATA: Date /(p Ride Owner r .I n,Irl. r"11, Lk yexi. e.� s Unannounced$�� dus Inspector 4X41Ride Name �LA J i C Re-inspection-Permit Event .51-Imr. ah (, ,,,,y MFG f. _,• , ai ; ,- Inspection/Red Tag History__,- Location Serial# IVA emporary ermanent USAID# Location When Facing: Permit# L. R. Z1, '-N 3(:;r KIDDIE NON-KIDDIE PE REQUIREMENTS: (Check each requirement as it is accomplished or place(N)if not applicable) 1. RIDE STATUS 2. INSTALLATION 3.STRUCTURAL a.(, ermit a.( locking a.( Wydraulics/Pneumatics b.(1139surance b.( •rPencing/Guarding b.(,�Pins/Bolts/Keys c.( C mpliance/NDT c.(.4'Braces/Guys/Anchors c.( 'Structural Integrity d.(/ilanuals d.(,�tigns d.( �<iresMlheels/Casters e.(,)rElectrical e.,(,),bearings/Spindles/Axles f. (,.jTrack/Rim iron 4.ATTACHMENTS 5.OPERATION 6. OTHER a.(JoGen Attachments a.(,yOPM Check a.V4'Automatic Sprinkler/Smoke Detector b.( Karrier/Tubs b.( �tontrols b.�'1)Mlater Quality c.(;)'Restraints c.( *Brakes c.(Y!3ungy Cords d.(,.�i'Sweeps d.(4 Limit Controls d.(NCranes e.VVComments DEFICIENCIES: RESULTS: All b i r PURSUANT TO Section 616.242(7),F.S.,ANINSPECTION 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.0 and the deficiencies iencies 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 she for -fide are available to the operator,and the last 14 daily inspection reports were completed and available upon re eTManager Sign.1ire . Inspector's at 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 e f ■ 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 FDACS-03419 Rev. 12109 FloridaDepartment 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@FreshFromFlodda.com DATA: Date -1 �P Ride Owner ) Q �_0'kN yy1 ,'tilt,k'6 Schedule -Unannounced Inspector sty,,4- , Ride Name 1'4�y �(fS t Re-inspection-Permit Event pS r, MFG ,t7 f!C') Inspection/Red Tag History,-- I Location Serial# A)A <iemor -Permanent USAID# 1 N H'7 Location When Facing: Permit#• ` 2fGczlo L. (7 yy+r R. �r�i �ID NON-KIDDIE SUPER REQUIREMENTS:(Check each requirement as it is accomplished or place(N)if not applicable) 1. RID -STATUS 2. INSTALLATION 3.STRUCTURAL a.(-r ermit a.( locking a.(,�Hydraulics/Pneumatics b.( 'I surance b.( Fencing/Guarding b.(,�Pins/Bolts/Keys C.( Compliance/NDT C.( aces/Guys/Anchors c.( tructuralIntegrity d.( YIIAanuals d.( Signs d.(ITires/Wheels/Casters e.(�Electrical e.( Oearings/Spindles/Axles f. (-"Track/Rim Iron 4.ATTACHMENTS 5.OPERATION 6.OTHER a.( en Attachments a.( � RPM Check a.0 Automatic Sprinkler/Smoke Detector b.(j Carrier/Tubs b.("rControls b.(,4�Water Quality c.( (Restraints c.( fBrakes c.(AJ Bungy Cords d.(.-)Sweeps d.( 4 Limit Controls d.(A)Cranes e.Q4 Comments DEFIC NCIES: Ok IOU, A44- RESULTS:RESULTS: PURSUANT TO Section 616. 42(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 f s for this ride are available to the operator, d th last 14 daily inspection reports were completed and available upon re ; er/Manager Signa Inspector's at PURSUANT TO Section 6116$i2(7),F.S.,the above identified amusement ride does not megt the requirements;of Section El 616.242, F.S.and Rule Chapter 5J-18, F.A.C.and shall not operate until it passes a subsegyent inspection by the Department. STOP OPERATION ORDER(FDACS 03545,Rev. 12/09)# Owner/Manager Signature Inspector's Signature FDACS-03419 Rev. 12/09 White/Bureap 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 FDACS-03419 Rev. 12/09 Ftrid� Department of Agriculture re and Consumer Services,.,,,'of Consumer Services/Bureau of Fair Rides Inspect on AMUSEMENT RIDE INSPECTION REPORT Section 616.242(4),Florida Statutes Rule 5J-18.0012,Florida Administrative Code ADAM H.PUTNAM -S COMMISSIONER Phone 1-800-435-7352;Fax(850)410-3797 FairRides@FreshFromFlorida.com DATA: Date ' - Ride Owner ;f. AL1 ,lite,c<' cheduteUnannouncd Inspector j�•M, {� (c Ride Name 6(LiJJ:,1 & S Re-inspection-Permit Event fj� aSG �-. �'y<� MFG Inspection/Red Tag History' Location Serial# AIA empora Permanent USAID# `( ��/ Location When Facing: Permit# i44 R. l'1 c.K KIDDIE EON-KIDDY SUPER _ REQUIREMENTS:(Check each requirement as it accomplished or place(N)if not applicable) 1. RIDE STATUS 2. INSTALLATION 3.STRUCTURAL . a.( ermit a.(,)~Blocking a.(,rHydraulics/Pneumat'ics' = RjL b.(4Insurance b.(-),Fencing/Guarding b.(�Pins/Bolts/Keys c.(-j' ompliance/NDT c.(,�Braces/Guys/Anchors c.( Otructural Integrity d.( Manuals d.( ''Signs d.(- Tires/Wheels/Casters A e.(,-YElectrical e.(.)'Bearings/Spindles/Axles f. (.-YTrack/Rim Iron 4.ATTACHMENTS 5. OPERATION 6. OTHER a.(-'Gen Attachments a.(-�RPM Check a."Automatic Sprinkler/Smoke Detector b.(,,YCarrier/Tubs b.(- Controls b.(ev)Water Quality c.(-�Restraints c.(-Mrakes c.(ny Bungy Cords d.(,*Sweeps d.(-1 Limit Controls d.(/'a Cranes e.(A4 Comments DEFICIENCIES: r__41 41 0!56 : 7/��� f/t/t�tc���—C? Al apj> 41 ,,V � 3 43 ,O'V 17/1„a: RESULTS: PURSUANT TO Section 616. 42(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.a d 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!pct sheets for this ride are available to the operator,and the last 14 daily inspection reports w completed and availabl7uA�e er/Manager Signature' Ins p s ure PURSUANT TO Section 616. 42(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.12109 White/BureaW Canary/Owner or Manager Pink/Event Inspection of L` 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 FDACS-03419 Rev. 12/09 -Fiorid D�epartrhbht of Agriculture and,ConsumerServtces� + Division Of Consumer Services/Bureau of Fair Rides Inspection AMUSEMENT RIDE INSPECTION REPORT 4D i 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@FreshFromF[orida.com DATA: Date " . � - (v Ride Owner /V l oe_; (tN fYl.efLtX `5 ched ed-Unannounced Inspector n V B Ride Name Re-inspection-Permit Event .St. uZQs4 Cf MFG Inspection/Red Tag Historr— Location "q 1"6 M I S!Jv A-J Serial# IVA Permanent USAID# a _ Location When Facing: Permit# s .-'210 t1 - L. � -.0 R. KIDDIE QW-OW QW-OWSUPER REQUIREMENTS: (Check each requirement as it is accomplished or place(N)if not applicable) 1. RIDE STATUS 2. INSTALLATION 3. STRUCTURAL a.( Permit a. a.(� Hydraulics/Pneumatics b.( Insurance b.( '}'Fencing/Guarding b.(4 Pins/Bolts/Keys c.(,}Compliance/NDT c.( ys/Anchors c.(-Y Structural Integrity d.( )Manuals d.(,fSigns d.( +TiresNVheels/Casters e.(,) Electrical e.(-i"Bearings/Spindles/Axles f. (A/,Track/Rim Iron 4. ATTACHMENTS S.OPERATION 6.OTHER a.( Gen Attachments a.( RPM Check a.(,fyAutomatic Sprinkler/Smoke Detector b.( Y Carrier/Tubs b.(4ontrols b.(/1)✓Water Quality c.( TRestraints c.(j Brakes c.(/"ungy Cords d.( Sweeps d.(j Limit Controls d.(�-rCranes e.&Comments DEFICIENCIES: RESULTS: PURSUANT TO Section 616.242(7),F.S.,AN INSPECTION CERTIFICATE IS ISSUED,when box is checked. The above p identified amusement ride meets the requirements of Section 616.242, F.S. and Rule Chapter 5J-18,F.A.C.and the deft iencies noted above(if any)have been corrected. INSPECTION CERTIFICATE(FDACS 03550,Rev.01/09)# /y,6 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 �Hare available to the operator,a the la 14 daily inWecti nreport�� eted and available upon request. Zile 6r_/Manager SidinatureiV Inspector's Signature_ PURSUANT TO Section 616. 42(7),F.S.,the above identified amusement ride does not meet the requirements of Section 616.242, F.S.and Rule Chapt r 5J-18, 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 FDACS-03419 Rev. 12/09 White/Bureau Canary/Owner or Manager Pink/Event Inspection//of /4 r-• ' s , 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 FDACS-03419 Rev. 12109 _44` Florida Department of Agriculture and Consumer Services Division of Consumer Services/Bureau of Fair Rides.lnspection AMUSEMENT RIDE INSPECTION REPORT Section 616.242(4),Florida Statutes T 3 —7 i?_" 1 e 7 Rule 5J-18.0012,Florida Administrative Code ADAM H.PUTNAM COMMISSIONER Phone 1-800-435-7352;Fax(850)410-3797 �h FairRides@FreshFromFlorida.com �b �b� `�„ rV DATA. 7 X\N Date Ride Owner pi(�� r�1, t cjCt y, = Bd –Unannounced Inspector ) Ride Name F(d!q /-i0�� Re-inspection–Permit _ Event t r L-44 4( `IM< MFG 54 Inspection/Red Tag History-- Location Serial# NA Permanent USAID# 07<1{ltd Location When Facing: Permit# IRTS L. R. s rA" KIDDIE � 1,�- t' SUPER �Ur orr� REQUIREMENTS:(Check each requirement as it is accomplished or place(N)if not applicable) �op( � {.�1.RIDE STATUS 2.INSTALLATION 3.STRUCTURAL `J Cb, a. ermit a.( )Blocking a.(,.YHydraulics/Pneumatics �� b.(,<nsurance b.(,4,Pencing/Guarding b.W Pins/Bolts/Keys c.( ;AAmpliance/NDT c.( races/Guys/Anchors c.( )Structural Integrity d.KManuals d. igns d.(,4-Tires/Wheels/Casters e.( )Electrical e.Wl3earings/Spindles/Axles f. (i)Track/Rim Iron 4.ATTACHMENTS 5.OPERATION 6.OTHER a.(,4'Gen Attachments a.(,�RPM Check a.(,tyAutomatic Sprinkler/Smoke Detector b.(4Carrier/Tubs b.(4_:Controls b.(AM/ater Quality c.(i)�testraints c.(*fBrakes c.(&Bungy Cords d.( Sweeps d.(/�Limit Controls d.(A4 Cranes e.(ecomments DEFICIENCIES: 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 Rule Chapter 5J-18,F.A.C.and the deficiencies noted above(if any)have been corrected. INSPECTION CERTIFICATE(FDACS 03550,Rev.01/09)# /p4 d'/ 1- 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,aW the last 14 daily inspection reports were completed and available upon request. er/Manager Signatdre Inspector's Signature PURSUANT TO Section 616. 42(7),F.S.,the above identified amusement ride does not meet the requirements of Section 616.242, F.S.and Rule Chapt r 5J-18, 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 FDACS-03419 Rev. 12/09 White/Bureau Canary/Owner or Manager Pink/Event Inspection of�G s , 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 FDACS-03419 Rev.12/09 y , •y I Flordo 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: E Date Ride Owner �t..tr` �� i�t�'CS�I?rl� chedule _ Unannounced InspectorRide Name fit, fir,s,°I { Re-inspection-Permit Event SG () ,;,vt�,, MFG Lc",le. N!u he t-Z Inspection/Red Tag History.,- Location Serial# ,^/,eem ora Permanent USAID# 1430-1'" Lbcation When Facing: Permit# 5"15 5:60 - R P``1, KIDDIE ON- SUPER '; REQUIREMENTS:(Check each requirement as it is accomplished or place(N)if not applicable) 1. RI - STATUS 2. INSTALLATION 3. STRUCTURAL a.( P rmit a.( locking a. ydraulics/Pneumatics b.( surance b.( encing/Guarding b.(�ins/Bolts/Keys c.(�ompliance/NDT C.( races/Guys/Anchors c.(�tructuralIntegrity fl-�rvlanuals d.( Signs d.('rTires/Wheels/Casters e.("fElectrical e.( Bearings/Spindles/Axles f. (-TTrack/Rim Iron 4.ATTACHMENTS 5.OPERATION 6. OTHER aen Attachments a.( Check a. Automatic Sprinkler/Smoke Detector b.(-jCarrier/Tubs b.( ControlsM b.(�Water Quality c.( Restraints c.(jBrakes c.(w)BungyCords d.( ISweeps d.(-) Limit Controls d.M Cranes e.N Comments DEFICIENCIES: 1 � ' RESULTS:/Jo (� 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. and the of iencies 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 x Section 616.242(16), F.S. and the manufacturers operating instructions or the operating fact ets is ride are available to the operator,an the last 14 daily inspecti n reports were completed and available upon requ OAnqF/Mpnager Inspector's SigpAVGK PURSUANT TO Section 616. 42(7),F.S.,the above identified amusemeoT ride does not meet the requirements of S tion ❑ 616.242, F.S.and Rule Chapt r 5J-18, F.A.C.and shall not operate until it passes a subsequent inspection by the Department. STOP OPERATION ORDER(FDACS 03545,Rev. 12109)# Owner/Manager Signaturez Inspector's Signature FDACS-03419 Rev. 12/09 WhiteBurea' Canary/Owner or Manager Pink/Event Inspection yof 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 FDACS-03419 Rev. 12109 Florida Department of Agriculture and Consumer Services Division of Consumer Services/Bureau of Fair Rides Inspection (AMUSEMENT RIDE INSPECTION REPORT Ila 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@FreshFromFlodda.com DATA: Date Ride Owner Mlj& jr&n 11A. JLAJ: Sched -Unannounced Inspector V11 t4l*f 6 Ride Name l Re-inspection_Permit Event �S A0.5,4 [.»;t, 1� MFG rn },I t'c 114 P ( Ins tion/Red Tag History__ -- Location Serial# MA mporary— ermanent USAID# G Location When Facing: Permit# _3. L. ... ~C C : R. F KIDDIE ON- SUPER REQUIREMENTS: (Check each requirement as it is accomplished or place(N)if not applicable) 1. RIDE STATUS 2. INSTALLATION 3.STRUCTURAL a.( ermit a. locking a.( ydraulics/Pneumatics b.( nsurance b. Fencing/Guarding b.('�Pins/Bolts/Keys C.( C mpliance/NDT C.( races/Guys/Anchors c.(*,Structural Integrity d.V anuals d.( igns d.( Tires/Wheels/Casters e.( Electrical e.( Bearings/Spindles/Axles f. ( )Track/Rim Iron 4.AT .ACHMENTS S.OPERATION 6. OTHER a.( Gen Attachments a.( PM Check a.(�Automatic Sprinkler/Smoke Detector b.(�Carrier/Tubs b.( ontrols b.M Water Quality c.(•'Restraints C. akes C.( Bungy Cords d.(4'Sweeps d.( Limit Controls d.H Cranes e.M Comments DEFICIENCIES: j RESULTS: < (' 5 r7 PURSUANT TO Section 616.F42(7),F.S.,AN INSPECTION CERTIFICATE IS ISSUED,when box is checked. The above identified amusement ride meats the requirements of Section 616.242; F.S.and Rule Chapter 5J-18,F.A. 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 fac sheets„ for this ride are available to the operator, d the last 14 daily inspecti n reports were completed and available upon reque, ,f� _. .. �... P” J Owner/Manager Signature Inspector's Si 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 DATE FDACS-03419 Rev.12109 - ' 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 1-800435-7352;Fax(850)410-3797 FairRides@FreshFromFlorida.com DATA: pp Date Ride Owner fV 1 pG(0e'0, tM,ct1CV 5 chedule —Unannounced Inspector 5f Vj 4-- =k Ride Name Re-inspection—Permit Event .J( G:54 G�, �-� *� MFG fit, r S4-,C &C(cs Inspection/Red Tag History Location Serial# Qem or Permanent USAID# Location When Facing: Permit# • L. C. r ,,,+r R. f�tlU '.r KIDDIE 'NA SUPER REQUIREMENTS:(Check each requirement as it is accomplished or place(N)If not applicable) 1. RIDE STATUS 2. INSTALLATION 3.STRUCTURAL a.( ermit a.(-TBlocking a.(,,3 Hydraulics/Pneumatics b.( surance b.( Fencing/Guarding b.(-,Pins/Bolts/Keys c.( ompliance/NDT c.( races/Guys/Anchors c.( *Structural Integrity d.( Manuals d.(4SSigns d.(4Tires/Wheels/Casters e.(lj'L=llectrical e.( 'Bearings/Spindies/Axles f. (,, ,Track/Rim Iron 4.ATTACHMENTS 5.OPERATION 6.OTHER a.( V3en Attachments a.( PM Check a#4 Automatic Sprinkler/Smoke Detector b.( Carrier/Tubs b,( ntrols b.( Water Quality c.( fRestraints c.( Drakes c.�Bungy Cords d.(,4-Sweeps d.(,00l Controls d.W Cranes e.N Comments DEFICIENCIES: AiM j1l:j 1Al 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 Rule Chapter 5J-18,F.A.C.and the deficiencies noted above(if any)have been corrected. INSPECTION CERTFICATE(FDACS 03550,Rev.01/09)# O 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 operatin ac eats for this ride are available to•the operator,arjO the I st 14 daily inspection reports were completed and available upon r e 4/Manager Signatulte Inspector's PURSUANT TO Section 616. 42(7),F.S.,the above identified amusement ride does not meet the requirements of Section 616.242, F.S.and Rule Cha pt r 5J-18, 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 4,111 Inspector's Signature FDACS-03419 Rev. 12/09 White/Bureau Canary/Owner or Manager Pink/Event Inspection�loof Ito 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 FDACS-03419 Rev. 12/09 Florida Department of Agriculture and Consumer Services a ' 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 1-800-4354352;Fax(850)410-3797 FairRides@FreshFromFlodda.com DATA: Date '' �"( (ta Ride Owner �' y tfc c-r-\ a A d.Uv'c,X,9 the u -Unannounced Inspector Ride Name 6 5,4.1 r'Lt4.�, Re-inspection—Permit Event -3T,120 "( 4.e"c; MFG L k,(d(f <S f Inspection/Red Tag History_ Location �`-" "`?'`" f"i �� Serial# �' `w mpor Permanent USAID# j; Location When Facing: Permit# 3 -X-0 L./t-�I + A R. J—X �w � KIDDIE _ SUPER REQUIREMENTS:(Check eacrequirement as it is accomplished or place(N)if not applicable) 1. RIDE STATUS 2. INSTALLATION 3.STRUCTURAL a.( )Permit a.(efBlocking a.( ,yi-lydraulics/Pneumatics b.(Xinsurance b.(,yFencing/Guarding b.( ,� s/Bolts/Keys c.(4 Compliance/NDT c.( ),Braces/Guys/Anchors c.( Structural Integrity d.(�'Manuals d.( }Signs d.(y Tires/Wheels/Casters e.(4 Electrical e.o-}Bearings/Spindles/Axles f. (11f'Track/Rim Iron 4.ATTACHMENTS 5.OPERATION 6. OTHER a.(rj Gen Attachments a.(/t RPM Check a.(#�,Automatic Sprinkler/Smoke Detector b.(#Karrier/Tubs b.(?+Controls b.(h4-Water Quality c.(19 Restraints c.(�Brakes c.(4Bungy Cords d.(Il Sweeps d.ffLimit Controls d.(-)Cranes e.("' Comments DEFICIENCIES: Hif,sem..✓ / A? Ic yr o o4--" /N" ew i• '? RESULTS:' PURSUANT TO Section 616.242(7),F.S.,AN INSPECTION CERTIFICATE IS ISSUED,when box is checked. The above 91 identified amusement ride meets the requirements of Section 616.242, F.S.and Rule Chapter 5J-18,F.A.C.and the dgficiencies 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 rideare available to the operator,a the I t 14 daily inspection reports were completed and available upon request. / A erV✓ er/Mary9ger'Sign u e Inspector's Signature PURSUANT TO Section 616. 42(7),F.S.,the above identified amusement ride does not meet the requirements of Section 616.242, F.S.and Rule Cha pt r 5J-18, 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 Signature Inspector's Si ' P FDACS-03419 Rev.12/09 White/Bureap Canary/Owner or Manager Pink/Event Inspection/./of /4, 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 FDACS-03419 Rev.12/09 Florida Department of Agriculture and Consumer Services Division of Consumer Services/Bureau of Fair Rides Inspection ' AMUSEMENT RIDE INSPECTION REPORT Section 816.242(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 Ride Owner MG u, t1l J LAAVS Schedu –Unannounced Inspector y v ;�}')t T- Ride Name 01 t r l, c,Ca 5 Re-inspection—Permit Event X056 d, MFG ' Inspection/Red Tag History--- Location Serial# NA Permanent USAID# Location When Facing: Permit# f /' L.kjL • all ' R. C e, Skl e KIDDIE <6@NSUPER REQUIREMENTS:(Check each req irement as it is accomplished or place(N)if not applicable) 1. RIDE STATUS .2. INSTALLATION 3. STRUCTURAL a. rmit a.( cking a.(1J Hydraulics/Pneumatics b.( surance b.( encing/Guarding b.(' Pins/Bolts/Keys c.(nlompliance/NDT c.( 4_traces/Guys/Anchors c.(1fstructural Integrity d.( anuals d.( Signs d.(,'Tires/Wheels/Casters e.( 1*8ectrical e.(,fBearings/Spindles/Axles f. ( -TTrack/Rim Iron 4.A ACHMENTS 5. OPERATION 6.OTHER a. en Attachments a. PM Check a.( Automatic Sprinkler/Smoke Detector b. : Carrier/Tubs b.( Controls b.(-'fWater Quality c.(j Restraints c.('f Brakes c.( Bungy Cords d.(4Sweeps d.(' Limit Controls d.�Cranes e.M Comments DEFICIENCIES: 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 Rule Chapter 5J-18,F.A.Q. nd the deficiencies noted above(if any)have beer)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 is f this ride are available to the operator,a d thVast 14 daily inspection reports were completed and available upon requ Pwn6r/Manag6r Sigha)ft J InspectorsSi ure PURSUANT TO Section 616. 42(7),F.S.,the above identified amusemen ride does not meet the requirements of Section 616.242, F.S.and Rule Chapt r 5J-18, F.A.C.and shall not operate until it passes a subsequent inspection by the Department. STOP OPERATION ORDER(PDACS 03545,Rev. 12/09)# Owner/Manager Signature Inspector's Signature. FDACS-03419 Rev. 12/09 White/Burea� 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 FDACS-03419 Rev. 12109 ' Florida Department of Agriculture and,Consumer Services Division of Consumer Services/Bureau of Fair Rides Inspection AMUSEMENT RIDE INSPECTION REPORT 4a 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 Fa!rRides@FreshFromFlodda.com DATA: Date Ride Owner N � chedule Unannounced Inspector a N7 Ride Name ( C I< - . �I G )10 Re-inspection-Permit Event - U5G c;(" L �*�q MFG `_> - , I(' i g_ S Inspection/Red,Tag Histopr--1 Location i $-XAV n.•,r Serial# .41A T ora - rmanent USAID# 0 q ' Location When Facing: Permit# L. f''rn R. KIDDIE O - SUPER REQUIREMENTS:,(Check each requirement as it is accomplished or place(N)if not applicable) 1 LRIDE STATUS 2. INSTALLATION 3.STRUCTURAL a.( ermit a.(e) Blocking a.(e)Hydraulics/Pneumatics b.(' surance b:(/) Fencing/Guarding b.kj Pins/Bolts/Keys C.( � mpliance/NDT c.(f) Braces/Guys/Anchors c.(/f Structural Integrity d.K Manuals d.(j Signs d.( Tires/Wheels/Casters e.(') Electrical e.(IBearings/Spindles/Axles f. (I Track/Rim Iron 4.ATTACHMENTS 5. OPERATION 6. OTHER W-(-TG-en Attachments a.(/) RPM Check a. utomatic Sprinkler/Smoke Detector b.( Carrier/Tubs b.(e)Controls b.(�ater Quality C.( Restraints c.(�Brakes c.(/k..Bungy Cords d.( )Sweeps d.( )`Limit Controls d.('y Cranes DEFICIENCIES: 3 tri �,ra..,ic .z 4 Oz/ aN "� T y F'c.ve.ts. L..ee,/Q' rY'c io.v .�-a�f �� T�?"m �:2' ,6-��Jc f't��,-w° !9'e,►,�1... ' RESULTS: PURSUANT TO Section 616.242(7),F.S.,AN INSPECTION CERTIFICATE IS ISSUED,when box is checked. The above J@ 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)# /.Po i1y 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 ide are available to the operator,and fhe las 4 daily inspection reports were completed and available upon request. r� OfA er/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 W 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 FDACS-03419 Rev. 12/09 F ` 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 �. -110 Ride Owner I it LTi, th (AXIV S he u -Unannounced Inspector ,,t ,tN fw Ride Name a .ac, Re-inspection-Permit EventL., MFG lnspection/Red Tag History.• Location Serial# !-t/ ra - ermanent USAID# Z-3/ Location When Facing: ermit# L. - R. C f ; x /KIDDIE NON-KIDDIE SUP , 1, C" REQUIREMENTS:(Check each requirement as it is accomplished or place(N)if not applicable) 1. RIDE STATS 2. INSTALLATION 3.STRUCTURAL a.(oofeermit a.( locking a.(*Hydraulics/Pneumatics b.( nsurance b.(ITencing/Guarding b.(,,YPins/Bolts/Keys c. Compliance/NDT c.( .races/Guys/Anchors c.( .Structural Integrity s, d.(- anuals d.(ljSigns d.(�Tires/Wheels/Casters e.(,TElectrical e.(-Bearings/Spindles/Axles f.(,Track/Rim Iron 4. ATTACHMENTS 5.OPERATION 6.OTHER a.(4 Gen Attachments a.(?RRPM Check a.(,IJj Automatic Sprinkler/Smoke Detector. 4 . b.(., Carrieraubs b.( _'>ntrols b.W Water Quality c.(.),Restraints c.( rakes c.(4) Bungy Cords .d.(.+Sweeps d.( omit Controls d.(&)Cranes e.N Comments Dom NC4l S 6,4 14L4 + t C• 16 (5 4- (69 F,)P,t s :u v ©5+ In 4�'AA 11 J 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 Rule Chapter 5J-18,F.A. d the deficiencies ff 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 operatin ac heets for this ride are available to the operator,gpd the last 14 daily inspection reports were completed and available upon r 6PJner/Manager Si atu.r InspeclofflOWe 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 wits in 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 i 41 FDACS-03419 Rev. 12109 Florida'Department of Agriculture acid 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 1-800435-7352;Fax(850)410-3797 FairRides@FreshFromFlorida.com DATA: Date Ride Ownerule Unannounced Inspector � �r,�,d Ride Name '" 1+ A l;yah, i: ) Re-inspection—Permit Event MFG )`b 6 Inspection/Red Tag History--- Location /'"1�A�-i to %+� d Serial# N14 em ora Permanent USAID# Q) " Location When Facing: Permit# c; 7,3 L. , R. /_',A.+t KIDDIE O - w SUPER 7 REQUIREMENTS:(Check each requirement as it is accomplished or place(N)if not applicable) 1. RIDE STATUS 2. INSTALLATION 3.STRUCTURAL'- a.(.4Permit a.(,# ) Blocking a.(,�Hydraulics/Pneumatics b.(,r�'I'�surance b.(i) Fencing/Guarding b.(4Pins/Bolts/Keys c.(., ompliance/NDT c.(,}Braces/Guys/Anchors c.( -I Structural Integrity d.(-Manuals d.( 4 Signs d.(.-)Tires/Wheels/Casters e.( Electrical e.( rBearings/Spindles/Axles f. (I Track/Rim Iron 4.ATTACHMENTS 5. OPERATION 6. OTHER a.(,�Gen Attachments a.(AfRPM Check a.(o6'Automatic Sprinkler/Smoke Detector b.(11 Carrier/Tubs b.(�)Controls b.(4"ater Quality c.(IlRestraints c.(•) Brakes c.(e}Bungy Cords d.(-Sweeps d.(/j Limit Controls d.(✓''}Cranes e.�.)Comments DEFICIENCIES: 0 ger rt /J . ' r A leel-IV s Ts f*w e. 4 /�,i►w..P ivy t k Gv'VY RESULTS: PURSUANT TO Section 616.242(7),F.S.,AN INSPECTION CERTIFICATE IS ISSUED,when box is checked. The above 4 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)# /'P 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 responsibleforoperating this ride has been trained in accordance with Section 616.24216); F.S. and the manufacturers operating instructions or the operating fact sheets his ride are available to the operator,a tFo I st 14 daily�inpec ion reports were completed and available upon request. ner/Manager Signa re" 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 40of/4 k 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 FDACS-03419 Rev. 12/09 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 It" l' Ride Owner )11 d ly- f�l, LAA t r Scher—Unannounced Inspector * ,"-" ,lam: Ride Name Re-inspection—Permit Event L,rhc. MFG t ,''• ` Inspection/Red Tag History..--' Location Serial# AIA Permanent USAID# Location When Facing: Permit# S' L. R. KIDDIE SUPER REQUIREMENTS:(Check each requirement as.it is accomplished or place(N)if not applicable) 1. RIDE STATUS 2. INSTALLATION 3. STRUCTURAL a.i ermit a.(,,YBlocking a.(,,�. ydraulics/Pneumatics b.( lnsurance b.(IFencing/Guarding b.(IPins/Bolts/Keys C.( ompliance/NDT c.(,�jBraces/Guys/Anchors c.(,rfStructuralIntegrity d.(4wlanuals d.(,'Signs d.(/rTires/Wheels/Casters e.(,, Electrical e.(-YBearings/Spindles/Axles f. Track/Rim Iron 4.ATTACHMENTS 5.OPERATION 6. OTHER a.( Gen Attachments a.( PM Check a.(A'Automatic Sprinkler/Smoke Detector b.( )Carrier/Tubs b.( Controls b. Water Quality c.(4 Restraints c.(/rBrakes c.M Bungy Cords d.(-)Sweeps d.(rf Limit Controls d.(? Cranes e.qj Comments DEFICIENCIES: (" rf, 55'rj 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 Rule Chapter 5J-18, F.A.Q.a d 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 operatingf ct s for this ride are available to the operator;an the l t 14 daily inspection reports were completed and available upon re st. 0r/Manager Sign ture Inspector 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/20of A* 01 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 FDACS-03419 Rev. 12109 x 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.PUT" COMMISSIONER Phone 1-800-435-7352;Fax(850)410-3797 ,A FairRides@FreshFromFlorida.com DATA: Date / 1 — �f1 Ride Owner j(VA WC. Schedu a Unannounced Inspector Ride Name [ ;�� Re-inspection—Permit Event {- 4A 0!54 MFG 4' -1r -±!C - Inspection/Red Tag Histcjry.� Location Serial# A Aempora ---Permanent USAID# (p' Location When Facing: Permit# J tai L. +° eOl +.t. R. bm KIDDIE - D- SUPER REQUIREMENTS:(Check each requirement as it is accomplished or place(N)if not applicable) 1. RIDE STATUS 2. INSTALLATION 3. STRUCTURAL a.(,+ grmit a k,)Blocking a.4-) Hydraulics/Pneumatics b.(,�TR"surance b ) Fencing/Guarding b. Pins/Bolts/Keys c.G� mpliance/NDT c.(.fiBraces/Guys/Anchors c.("�tructuralIntegrity d: anuals d.(,j S' ns d.(' TiresM/heels/Casters (, e. -jfElectrical e.( earings/Spindles/Axles f. ( Track/Rim Iron 4.ATTACHMENTS 5. OPERATION 6. OTHER a.�4Gen Attachments a.(,)1RPM Check a.V)'Automatic Sprinkler/Smoke Detector b.(,�Carrier/Tubs b.(4Controls b.(/.,)'Water Quality c.( estraints c.(-I Brakes c.(#*Bungy Cords d.( Sweeps d.(,4Limit Controls d.(Vranes e.( IComments DEFICIENCIES: 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 Rule Chapter 5J-18, F.A.C.and the deficiencies noted above(if any)have been corrected. INSPECTION CERTIFICATE(FDACS 03550,Rev.01/09)# /.0-0/'0VP 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,a the I It 14 daily inspection reports were coin 1 -and available upon request. e/Manager Signat re ( Inspector's Signature PURSUANT TO Section 616.242(7),F.Sthe above identified amusement ride does not meet the requirements of Section 616.242, F.S.and Rule Chapter 5J=18, FIC. 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 Inspections of�� r , 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 FDACS-03419 Rev. 12109 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 Ride Owner W 0 6(e(',,,N �1 l t chedu�le Unannounced Inspector t Ride Name C Re-inspection-Permit Event 5 �,y^�Ci MFG ��/ f(--rcr, f,�- k f Inspection/Red Tag History. Location Serial# _f f/ ra Permanent USAID# :s F � Location When Facing: Permit# s L—) L.7, ' �O E'r R. i U U KIDDIE UPER 1 REQUIREMENTS:(Check each requirement as it is accomplished or place(N)if not applicable) 1. RIDE STATUS 2. INSTALLATION 3.STRUCTURAL a.(.-)*Permit a.(,..Y8locking a.(,.YHydraulics/Pneumatics b.( surance b.('�Fencing/Guarding b.(.4 Pins/Bolts/Keys c.(1 Compliance/NDT c.(,IBraces/Guys/Anchors c.( -Structural Integrity d.4manuals d.(�Signs d.( ,TiresMheels/Casters e.(-T"Electrical e.( -°Bearings/Spindles/Axles f. (-TTrack/Rim Iron 4.ATTACHMENTS 5. OPERATION 6. OTHER a.( en Attachments a.(,4 RPM Check a. Automatic Sprinkler/Smoke Detector b.(Aarrier/Tubs b.(-'f Controls b.(M Water Quality c.(..,r2estraints c.(;.YBrakes c.(w)Bungy Cords d.(*I Sweeps d.(-Limit Controls d.(/v)Cranes e.(v)Comments DEFICIENCIES: RESULTS: C 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.0 a d 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 f s s for this ride are available to the operator, j1he la 14 daily inspection reports were completed and available upon re ner/Manager SignatureF Inspector e PURSUANT TO Section 616.242(7),F.S.,the above identified-amus ment 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. 12109 White/Bureau Canary/Owner or Manager Pink/Event Inspection/hof�`► 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 FDACS-03419 Rev.12/09 Florida E�ipartment of Agriculture and Consumer Services Division of Consumer Services/Bureau of Fair Rides Inspection AMUSEMENT RIDE INSPECTION REPORT Ila 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 Fa!rRides@FreshFromFlorida.com DATA: Date- 'L - �� Ride Owner A-fe-3"'ot-0 eta rA V#qV Scheduled-Unannounced Inspector o rryy Ride Name : Re-inspection-Permit Event /2 sr-1 A. n..n MFG Inspection/Red Tag History Location Serial# Temporary-Permanent USAID# lal Y7 Location When Facing: Permit# J'OrPl�f 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.( ermit a.H Blocking a.(�) Hydraulics/Pneumatics b.( Insurance b.�.) Fencing/Guarding b.e)Pins/Bolts/Keys c.(j Compliance/NDT c.(.o)Braces/Guys/Anchors c.(,j Structural Integrity d.(, Manuals d.(.-,)Signs d.(,)Tires/Wheels/Casters w e.(-) Electrical e.(/ )Bearings/Spindles/Axles f. (.r'jTrack/Rim Iron 4.ATTACHMENTS 5.OPERATION 6. OTHER a. en Attachments a.O„RPM Check a.(/t,-,Automatic Sprinkler/Smoke Detector b.ey'Carrier/Tubs b.(,�Controls b.(A�Water Quality c.(-)'Restraints c.( yBrakes c.(dy�Bungy Cords d.(/�weeps d.( -Limit Controls d.(� Cranes e.( )Comments DEFICIENCIES: CaA) .L..o/h. Gia 4C A- f ao Carr 1010Xr 7--44, .? �v►'r� t'4 t ?j a Na? /ZV nvry l4/ar ,�, d rw/ : /t eT/Ord 4 J'a C�A 414 j-&A-'ret ?a)c a RESULTS: PURSUANT TO Section 616.242(7),F.S.,AN INSPECTION CERTIFICATE IS ISSUED,when box is checked. The above rP 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 f is ride are available to the operator,ancl the iasl 14 daily inspection reports were completed and available upon request _. ... Signature Inspectors Signature n r/Manager 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 Inspectionwof,90 l : i 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 FDACS-03419 Rev. 12109 i' 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@FreshFromFlodda.com DATA: Date ' " (- (a Ride OwnerSchedule Unannounced Inspector Ride Name I, 4:p Re-inspection-Permit Event 5+AoG of MFG (Ili NAe Inspection/Red Tag History--' Location Serial# Permanent USAID# 7 Location When Facing: Permit# .. L. o►' R. N! KIDDIE ON-KIDDIE SUPER REQUIREM each requirement as it is accomplished or place(N)if not applicable) 1. RIDE STATUS 2. INSTALLATION 3.STRUCTURAL a.( ermit a.�,Olocking a. Hydraulics/Pneumatics b:(*�Insurance b.(,-ffencing/Guarding b.,.-j Pins/Bolts/Keys c.(,'f°Compliance/NDT c.(;,rBraces/Guys/Anchors c.(-'rStructuralIntegrity d.(o' Manuals d. Signs d.(/yTires/Wheels/Casters e. >Electrical e.(AlA earings/Spindles/Axles f. l l rack/Rim Iron 4 ATTACHMENTS 5. OPERATION 6. OTHER a. en Attachments a.N RPM Check a. Automatic Sprinkler/Smoke Detector b.( arrier/Tubs b.(A.�Controls b.W)Water Quality e.(4yRestraints c.(1.) Brakes c.(�) Bungy Cords d.(#,),,Sweeps d.(1j-(-imit Controls d.M Cranes e.0 Comments DEFICIENCIES: ra!c (all ) ff"'*�l �.v �" .S'' t ,�s l�40,000,q 7 P �, ,rDWle4 i v6 /r y" .6wS >oc e (-z' G)e, 2 i G C to T ^ .!'f v c k�< RESULTS: PURSUANT TO Section 816.242(7),F.S.,AN INSPECTION CERTIFICATE IS ISSUED,when box is checked. The above KI 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.01109)# / p Q 14 I acknowledge receipt of this inspection report and the NOTICE OF RIGHTS on the reverse side of this forma 1 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 61'6.242(16), F.S. and the manufacturers operating instructions or the operating fact sheets for this r' ar avai able to the operator,aV the st 14 daily i s ection reports were�comi a rtd.available upon request. er/Manager Sign „ re Jr Inspector's Signature i PURSUANT TO Section 616.242(7),F.S„the above identified amusement ride does not meet the requirements of Section 0 616.242, F.S.and Rule Chapter 5J-18, F.A.C.and shall not operate until it passes a subsequent inspection by the Department. f STOP OPERATION ORDER(FDACS 03545, Rev. 12/()9)# Owner/Manager Signature Inspectors,Signature FDACS-03419 Rev. 12109 White/Bureau Canary/Owner or Manager Pink/Event Inspection 7 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 FDACS-03419 Rev. 12109