Application for a Permit to Operate an Amusement Device

Application for a Permit to Operate an Amusement Device
AMUSEMENT DEVICES REGULATIONS 1978
Machinery Act 1950,
Form 4
Application for a Permit to Operate an Amusement Device
To Waitaki District Council
I/We………………………………………………………………………………………
Of……………………………………………………………………………………….hereby
Make application for a permit to operate a (please specify each device)
……………………………………………Registration No. ……………Expiry Date: ……………..
……………………………………………Registration No. ……………Expiry Date: ……………..
At………………………………………………………………………………………………
from…………………..to……………………..
Name of operator if other than owner …………………………………………………………………
Site contact person ………………………………………………. Phone No. ……………………….
Please Note:
(a) Each device’s certificate of registration and conditions of operation are to be attached
(b) I, the applicant, hereby signify by the signing of this application that I have read,
understand and agree to abide by the requirements of the Machinery Act 1950, in
particular sections 8, 12, 18, 19, 19a, 21a and 38, and the Amusement Device
Regulations 1978, in particular regulations 11,14,15 and 18-23.
(c) A Council officer has to inspect the device before a permit can be issued.
(d) No amusement device may operate without a permit.
(e) The prescribed fee of $11.50 (per device) for the first 7 days or part thereof
(f) For each additional device operated by the same owner, for the first 7 days or part
thereof $2.25
(g) For each additional device $1.15 for each further period of 7 days or part thereof.
Signed …………………………………………Phone No. …………………………………..
Date …………………………………………..
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