Doc # 449743 Page 1 of 1 BA AMR Form 4
Application for a permit to operate an
amusement device
Amusement Devices Regulations 1978
Version: 4
Date: January 2020
S
end or deliver your application to: Web: www.timaru.govt.nz
Building Services, Timaru District Council, Telephone: (03) 687 7236
2 King George Place, PO Box 522, Timaru 7940 Email: building@timdc.govt.nz
I / WE
Applicants name:
Mailing address:
Contact details: Landline number:
Daytime number:
Facsimile number:
Email address:
Mobile number:
After hours number:
HEREBY MAKE AN APPLICATION FOR A PERMIT TO OPERATE A
Name of device: Registration number:
AT
Location of device (street address):
TIME PERIOD
Date from: Date to:
APPLICANT DECLARATION
I certify that, having regard to the situation in which the device is erected, it can be operated without danger to persons operating or
using it or in its vicinity. In support of this application, there is attached:
(a) The Certificate of Registration of the device.
(b) The prescribed fee: (per 1st 7 days): $11.50 for first device, $2.30 for each additional device. Any further period of 7 days (or part
thereof): $1:15 per device.
Name:
Signature: Date:
click to sign
signature
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