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2. OWNER/OPERATOR/PERSON ASSUMING RESPONSIBILITY
4. Company*
6. Address*
8. City*
9. State*
10. Zip*
12. Phone*
13. Email*
15. LOCATION OF DEVICES
17. Name
19. Address*
21. City*
22. State*
23. Zip*
25. Event Start Date*
26. Event End Date*
28. If a private inspector is being used, has a copy of their state certification been submitted with this application?

    1. Yes

    1. No
30. Attach Document
32. Has the certificate of insurance/proof of financial responsibility been submitted with this application?

    1. Yes

    1. No
34. Attach Document
38. Please list the name(s) and identification/serial number(s) for all amusement devices.
40. Amusement Device Name
41. ID/Serial Number
42. Classification
    -- Select One --Kiddie RideMajor RideSpectacular Ride
44. Amusement Device Name
45. ID/Serial Number
46. Classification
    -- Select One --Kiddie RideMajor RideSpectacular Ride
48. Amusement Device Name
49. ID/Serial Number
50. Classification
    -- Select One --Kiddie RideMajor RideSpectacular Ride
52. Amusement Device Name
53. ID/Serial Number
54. Classification
    -- Select One --Kiddie RidgeMajor RideSpectacular Ride
56. Amusement Device Name
57. ID/Serial Number
58. Classification
    -- Select One --Kiddie RideMajor RideSpectacular Ride
60. Amusement Device Name
61. ID/Serial Number
62. Classification
    -- Select One --Kiddie RideMajor RideSpectacular Ride
64. Amusement Device Name
65. ID/Serial Number
66. Classification
    -- Select One --Kiddie RideMajor RideSpectacular Ride
68. Amusement Device Name
69. ID/Serial Number
70. Classification
    -- Select One --Kiddie RideMajor RideSpectacular Ride
72. Amusement Device Name
73. ID/Serial Number
74. Classification
    -- Select One --Kiddie RideMajor RideSpectacular Ride
76. Amusement Device Name
77. ID/Serial Number
78. Classification
    -- Select One --Kiddie RideMajor RideSpectacular Ride
80. Amusement Device Name
81. ID/Serial Number
82. Classification
    -- Select One --Kiddie RideMajor RideSpectacular Ride
84. Amusement Device Name
85. ID/Serial Number
86. Classification
    -- Select One --Kiddie RideMajor RideSpectacular Ride
88. Amusement Device Name
89. ID/Serial Number
90. Classification
    -- Select One --Kiddie RideMajor RideSpectacular Ride
92. Amusement Device Name
93. ID/Serial Number
94. Classification
    -- Select One --Kiddie RideMajor RideSpectacular Ride
96. Amusement Device Name
97. ID/Serial Number
98. Classification
    -- Select One --Kiddie RideMajor RideSpectacular Ride
100. Amusement Device Name
101. ID/Serial Number
102. Classification
     -- Select One --Kiddie RidgeMajor RideSpectacular Ride
104. Amusement Device Name
105. ID/Serial Number
106. Classification
     -- Select One --Kiddie RideMajor RideSpectacular Ride
108. Amusement Device Name
109. ID/Serial Number
110. Classification
     -- Select One --Kiddie RideMajor RideSpectacular Ride
112. Amusement Device Name
113. ID/Serial Number
114. Classification
     -- Select One --Kiddie RideMajor RideSpectacular Ride
116. Amusement Device Name
117. ID/Serial Number
118. Classification
     -- Select One --Kiddie RideMajor RideSpectacular Ride
120. I hereby certify that all the information in this application is correct and all work will comply with the State Building Code and all other State and local laws, ordinances and regulations. I further understand that all information submitted will be reviewed prior to the issuance of a permit.
122. Signature of Applicant
124. Date
     Date
Leave This Blank:


126. 1. Receive an email copy of this form.
127. Email address

     This field is not part of the form submission.

128. Submit Submit and Print

* indicates a required field