Fillable Operating Permit Mailing address: 1000 East Grand Avenue, (Office of the Chief Information Officer)

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Operating Permit Mailing address: 1000 East Grand Avenue, (Office of the Chief Information Officer)

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Amusement Ride
Operating Permit
Instructions
Fees
Fees may be sent in with application or given to the inspector at the time of inspection. 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
Mailing address: 1000 East Grand Avenue, Des Moines, IA 50319-0209
Physical address: 150 Des Moines Street, Des Moines, IA 50309 (FedEx/UPS)
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.
Mailing address: 1000 East Grand Avenue, Des Moines, IA 50319-0209
Physical address: 150 Des Moines Street, Des Moines, IA 50309 (FedEx/UPS)
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
10.09.2018
100-001
Page 2 of 2
07.19.2016
100-001.1
Ride
Name
Trade
Name
Manufacturer
Serial
Number
# of
Blowers
1
st
Setup
Location
Ride
Name
Trade
Name
Manufacturer
Serial
Number
# of
Blowers
1
st
Setup
Location
Ride
Name
Trade
Name
Manufacturer
Serial
Number
# of
Blowers
1
st
Setup
Location
Ride
Name
Trade
Name
Manufacturer
Serial
Number
# of
Blowers
1
st
Setup
Location
Ride
Name
Trade
Name
Manufacturer
Serial
Number
# of
Blowers
1
st
Setup
Location
Ride
Name
Trade
Name
Manufacturer
Serial
Number
# of
Blowers
1
st
Setup
Location
Ride
Name
Trade
Name
Manufacturer
Serial
Number
# of
Blowers
1
st
Setup
Location
Ride
Name
Trade
Name
Manufacturer
Serial
Number
# of
Blowers
1
st
Setup
Location
Ride
Name
Trade
Name
Manufacturer
Serial
Number
# of
Blowers
1
st
Setup
Location
Ride
Name
Trade
Name
Manufacturer
Serial
Number
# of
Blowers
1
st
Setup
Location
Ride
Name
Trade
Name
Manufacturer
Serial
Number
# of
Blowers
1
st
Setup
Location
Ride
Name
Trade
Name
Manufacturer
Serial
Number
# of
Blowers
1
st
Setup
Location
Ride
Name
Trade
Name
Manufacturer
Serial
Number
# of
Blowers
1
st
Setup
Location
Ride
Name
Trade
Name
Manufacturer
Serial
Number
# of
Blowers
1
st
Setup
Location
Ride
Name
Trade
Name
Manufacturer
Serial
Number
# of
Blowers
1
st
Setup
Location
Ride, Inflatable and Generator List
Show Name: Permit #:
Amusement Event Itinerary
List all events that have been booked for this year in the state of Iowa and all events you expect to book. Write “tentative” on an
event that has not been finalized. Submit any updates as they become available to: amusement@iwd.iowa.gov.
Set up date/time is the date/time you begin unloading equipment. List approximate times if an exact time is not available.
Event
Name
Event Location
Name
Address
City
Set up
Date
Set up
Time AM PM
Event Start
Date
Event Start
Time AM PM
Event
End Date
Number of
Rides
Number of
Concessions
Number of
Inflatables
Event
Name
Event Location
Name
Address
City
Set up
Date
Set up
Time AM PM
Event Start
Date
Event Start
Time AM PM
Event
End Date
Number of
Rides
Number of
Concessions
Number of
Inflatables
Event
Name
Event Location
Name
Address
City
Set up
Date
Set up
Time AM PM
Event Start
Date
Event Start
Time AM PM
Event
End Date
Number of
Rides
Number of
Concessions
Number of
Inflatables
Event
Name
Event Location
Name
Address
City
Set up
Date
Set up
Time AM PM
Event Start
Date
Event Start
Time AM PM
Event
End Date
Number of
Rides
Number of
Concessions
Number of
Inflatables
Event
Name
Event Location
Name
Address
City
Set up
Date
Set up
Time AM PM
Event Start
Date
Event Start
Time AM PM
Event
End Date
Number of
Rides
Number of
Concessions
Number of
Inflatables
Event
Name
Event Location
Name
Address
City
Set up
Date
Set up
Time AM PM
Event Start
Date
Event Start
Time AM PM
Event
End Date
Number of
Rides
Number of
Concessions
Number of
Inflatables
Event
Name
Event Location
Name
Address
City
Set up
Date
Set up
Time AM PM
Event Start
Date
Event Start
Time AM PM
Event
End Date
Number of
Rides
Number of
Concessions
Number of
Inflatables
Show Name: Permit #:
No events scheduled as of: (date)
09.28.2018
100-001.2
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Operating Permit Mailing address: 1000 East Grand Avenue, (Office of the Chief Information Officer)

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Completed 13 August 2020

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