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Amusement Device Application

  1. OWNER/OPERATOR/PERSON ASSUMING RESPONSIBILITY

  2. LOCATION OF DEVICES

  3. If a private inspector is being used, has a copy of their state certification been submitted with this application?

  4. Has the certificate of insurance/proof of financial responsibility been submitted with this application?

  5. Please list the name(s) and identification/serial number(s) for all amusement devices.

  6. I hereby certify that all the information in this application is correct and all work will comply with the State Building Code and all other State and local laws, ordinances and regulations. I further understand that all information submitted will be reviewed prior to the issuance of a permit.

  7. Leave This Blank:

  8. This field is not part of the form submission.