Fillable Operating Permit 150 Des Moines Street Des Moines, (Office of the Chief Information Officer)

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Operating Permit 150 Des Moines Street Des Moines, (Office of the Chief Information Officer)

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  • 30 other fields

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File type: PDF

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BROWSE OFFICE OF THE CHIEF INFORMATION OFFICER (IA) FORMS

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Amusement Ride
Operating Permit
Instructions
Fees
Non-refundable permit fees are required at the time of submittal of application. Rides will not receive stickers and shall
not operate until the permit and inspection fees are paid. Cash will not be accepted. Payment must be made by check,
cashier’s check or money order payable to the “Iowa Division of Labor – Amusement Ride Safety.”
Permit Fees: $30.00 – 1-10 rides or concessions $40.00 – 11 or more rides or concessions
Inspection Fees: $250.00 – Major ride (more than 40 hours of work to assemble)
$110.00 – Adult ride (passengers weighing 75 lbs or more and less than 40 hours to assemble)
$75.00 – Kiddie ride – (passengers weighing 75 lbs or less)
$40.00 – Concession booth $40.00 – Inflatable
$40.00 – Blower $40.00 - Generator
Inspection
Your equipment must be inspected by a designee of the Labor Commissioner before it can be operated in Iowa. Contact
the Division of Labor as early as possible to schedule your inspection.
All rider safety signs shall be posted before the inspection. At the time of inspection the following must be presented to
the inspector:
maintenance logs
daily inspection logs
operator training logs
NDT documents if required
Certificate of Insurance
The certificate of insurance submitted with your application must:
Include “Iowa Division of Labor – Amusement Ride Safety, 1000 East Grand Avenue, Des Moines, IA 50319” as a
certificate holder
List included and excluded rides identified by the serial number
State effective dates of the insurance coverage
State a coverage amount of $1,000,000.00 or more per occurrence
Iowa Division of Labor
Amusement Ride Safety
150 Des Moines Street
Des Moines, IA 50309-1836
Phone: 515-725-5612/515-725-5608
Fax: 515-242-5076
amusement@iwd.iowa.gov
amusement.iowa.gov
It is illegal to operate an amusement ride or device without a permit. Submit a completed application and
certificate of insurance to the address above. The waiver section of the application form must be completed for a
permit application submitted after May 1. Failure to adequately justify an application submitted after May 1 may
result in denial of your operating permit. Permits expire annually on December 31
st
of the year issued.
Reporting Requirements
You must notify the Division of Labor:
immediately of an accident causing a death or injury needing more than first aid
in writing within 48 hours of a major breakdown
of any change in the owner’s contact information
of any change in your itinerary
If applying to self-inspect inflatables, you must submit both application forms. All criteria must be met.
Notification will be sent once a decision has been made.
Page 1 of 2
Amusement Ride Operating Permit Application
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.
150 Des Moines Street
Des Moines, IA 50309-1836
Phone: 515-725-5612/515-725-5608
Fax: 515-242-5076
amusement@iwd.iowa.gov
amusement.iowa.gov
FOR OFFICE USE ONLY
Permit #:
Permit Year:
Check #:
Inspections will not be scheduled until this form has been completed, signed and dated.
Show name
Owner’s name
Owner’s email address
Owner’s address
City
State
Zip
Owner’s phone number
Owner’s mobile number
Owner’s fax number
Billing address same as owner address
City
State
Zip
Billing contact name
Billing contact email address
Setup contact name
Setup contact mobile number
Setup contact email address
Is business incorporated? Yes No
If yes, in which State:
Is business a sole proprietor? Yes No
If, yes Social Security #:
Insurance Provider
Insurance Contact Name
Insurance Phone Number
Insurance Fax Number
Insurance Email Address
Waiver - Complete this section only if you apply after the May 1
st
deadline
Date I first knew an Iowa amusement permit would be needed for this calendar year:
I am applying for a waiver from the May 1
st
application deadline because:
I have read and understand the operating manuals for my equipment and the requirements of Iowa law governing amusement rides
and devices. I certify that everyone who works for me in Iowa will be trained to maintain and operate the equipment according to
applicable manuals and Iowa law. I certify that the information on this application form and on any attachments is true and accurate.
I understand it is illegal to operate an amusement ride or device without a permit and current inspection sticker.
Signature of Authorized Representative Title Date
Please keep a copy of the completed application package for future reference
02.02.2020
100-001
Page 2 of 2
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Operating Permit 150 Des Moines Street Des Moines, (Office of the Chief Information Officer)

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Completed 25 July 2020

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