Iowa Division of Labor
Amusement Ride Safety
150 Des Moines Street
Des Moines, IA 50309-1836
Application to Self-Inspect Air-Supported Structures
It is within the discretion of the Iowa Labor Commissioner to grant or deny this designation.
This designation will be denied if the operator does not have a history of safely operating inflatables in Iowa.
This designation will be denied if the operator will be running mechanical rides or covered concessions in Iowa.
This designation will be denied if training certificate is not provided.
Have you been trained by a third party provider to inspect inflatables? Yes No (If yes, attach a copy of training certificate)
Have you set up one or more air-supported-structures in Iowa in the last year? Yes No
In the past 5 years, has a patron been injured while using one of your air-supported-structures in any jurisdiction? Yes No .
Do you have written procedures as set forth in ASTM F770-15 for: Initial setup inspection: Yes No
Daily inspections: Yes No Periodic operating inspections: Yes No
Have you obtained and reviewed:
ASTM F2374-10: Yes No
Yes No ASTM F1193-14: Yes No
NFPA 70-2014 (NEC): Yes No 1910 (OSHA): Yes No
Iowa Code Chapter 88A: Yes No Iowa Amusement Ride Rules, Chapter 61 and 62: Yes No
Equal Opportunity Employer/Program
Auxiliary aids and services are available upon request to individuals with disabilities.
For deaf and hard of hearing, use Relay 711.
If the Labor Commissioner designates me to perform inspections on my own air-supported structures, I agree to:
Notify the Division of Labor of any change in my contact information or itinerary
Notify the Division of Labor immediately of an accident causing a death or injury resulting in treatment beyond first aid
Perform the inspections faithfully and thoroughly according to the applicable codes
Correct any hazards identified during the inspection before the equipment is operated
Complete and submit accurate inspection reports to the Labor Commissioner
Delay operation of the equipment until I receive the sticker from the Labor Commissioner and attach it to the equipment
Permit #: Permit year:
I certify that the information submitted on this form is true and accurate to the best of my knowledge.
Operator’s Name Operator’s Signature Date