Application for a Permit to Operate an Amusement Device

Application for a Permit to Operate an Amusement Device
Application for a Permit to Operate an
Amusement Device
(Amusement Devices Regulations 1978)
Applicant
Full name
Postal address
Representing (Name of organisation)
Business phone
Mobile phone
Email
Amusement Device Information
Pursuant to the Machinery Act 1950, I/We hereby make application for a permit to operate a:
at
from
to
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 or in its vicinity.
In support of this application, attached is:
•
The device’s certificate of registration
 yes
Prior to issuing a permit Council must be satisfied that:
•
An Engineer’s report certifying the ground on which the device is erected is capable of supporting it
without risk of subsidence.
There is sufficient clearance between any part of the device and any fixed or moving objects in its
vicinity to prevent injury to any person when the device is in operation
Protective fences or barriers, if required, are erected.
In all other respects, the erection and proposed operation of the device complies with the
Whakatāne District Council's bylaws.
•
•
•
Signed:
Fees:
Dated:
$11.30 one device
$2.30 each additional device
Office Use
Total fee payable:
Receipt number:
Code:
$
Total paid:
Date paid:
CS initials
Please forward original to Building and Monitoring and email a copy to [email protected]
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