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Health - Amusement Device

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Amusement Device Operation
Permit Application Form
Please return this form to: info@adc.govt.nz or Ashburton District Council, PO Box 94, Ashburton 7740
Applicant Details
Name:
Company Name:
Postal Address:
Physical Address:
Mobile number:
Business number:
Email address:
Event Information
Event Name
Held by:
Event Location:
Event Time and Date- From:
Device Information (please attach certificate of registration with application)
Reg. No.
Device
Owner
Expiry Date of Certificate
Fees (please pay fees with application)
1. The prescribed fee: $11.50
2. Additional fees:
a) For one device: for the first 7 days, or part thereof - $10 (+GST)
b) For each additional device operated by the same owner: for the first 7 days or part thereof -
$2.00 (+GST)
c) For each device: $1.00 (+GST) for each further period of 7 days or part thereof
Inspection
Please inspect before
Time:
Date:
I hereby make an application for permit to operate an amusement device and 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 on or in its vicinity.
Signed: _____________________________ Date: _________________________________
Notes for the applicant
1. Applications must be accompanied by a current Certificate of Registration and the application fee.
2. Applications must be received at this Office of the Ashburton District Council 10 full working days prior to the event.
Late applications will be charged an additional processing fee of $20. No applications may be accepted on the day of
the event.
3. Applications should state exactly where the intended amusement device site will be and include an ‘inspect by’ time
and a contact phone number, eg. Ashburton Domain on Saturday is not good enough.
4. Fees for permit applications are non-refundable. Applications are not transferable to other dates outside those on
the original application.
5. Rides should not commence before the device has been inspected and the permit issued.
6. Permits are generally issued on site at the time of inspection but, application must be made at the office of the
Ashburton District Council, 5 Baring Square West, Ashburton.
PRINCIPLE 3 OF THE PRIVACY ACT 1993
1. The purpose of which the information about you is being collected to comply with the licensing requirements of the
Machinery Act 1950 and the Amusement Devices Regulations 1978.
2. Intended recipients of personal information contained in the application form are:
(a) The Ashburton District Council, Environmental Services Department
(b) Department of Labour, Occupational Safety and Health
3. Name and address of the agency collecting and holding your personal information is:
Ashburton District Council
5 Baring Square West
Ashburton
4. The personal information about you is required by law and the supply of information by you is mandatory.
5. The consequences for yourself if you do not provide the information requested is that the Council may decline your
application.
6. Right of access to and correction of personal information.
With regard to personal information held about you by the Council which can be readily retrieved, you can
upon request:
(a) Obtain confirmation whether or not the Council holds personal information about you; and if so:
(b) Obtain access to that information.
You are entitled to request that the Council correct any personal information it hold about you. If the Council is
not willing to correct your personal information in the way you request, then you can require the Council to
attach a statement you prepare that will always be read with your personal information.
The Council will inform you of what steps it has taken in response to any request you may make to correct your
personal information.
Office Use Only:
Original Certificate sighted and copied? Yes No Certificate is current? Yes No
Registration number same as certificate? Yes No Invoiced? Yes No
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Health - Amusement Device

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Completed 3 July 2020

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