Free VARIANCE APPLICATION - Indiana

APPLICATION FOR ANNUAL PERMIT TO OPERATE AMUSEMENT DEVICE
State Form 323 (R5 / 3-08) Approved by State Board of Accounts, 2006

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INSTRUCTIONS:

1. 2. 3. 4. 5. 6.

Application and affidavit must be submitted thirty (30) days prior to opening date. Enclose check and valid certificate of insurance. Make checks payable to: Division of Fire and Building Safety. Notify this office by fax, mail, or e-mail two (2) weeks in advance to schedule annual inspection or changes in itinerary. Manuals, maintenance reports, and NDT reports (if required) for EACH device must accompany the device at ALL times. Reinspection fees shall be one-half (1/2) of the annual inspection fee. Subsequent inspection fee shall be one hundred dollars ($100) per device.
Name of owner

DEPARTMENT OF HOMELAND SECURITY DIVISION OF FIRE AND BUILDING SAFETY DIVISION OF AMUSEMENT RIDE SAFETY 402 West Washington Street, Room W246 Indianapolis, Indiana 46204 Telephone: (317) 232-2670 Fax: (317) 232-6609 www.in.gov/dhs

Doing business as (DBA) Address (number and street, city, state, and ZIP code) Telephone number Fax number

E-mail address

(

)
NAME OF DEVICE

(
IDENTIFICATION NUMBER

)
INSPECTION DUE (month, day, year) 16. 17. 18. 19. 20. 21. 22. 23. 24. 25. 26. 27. 28. 29. 30. NAME OF DEVICE IDENTIFICATION NUMBER INSPECTION DUE (month, day, year)

1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15.

Submit the current and updated itinerary using the application form as a second page to this form. LOCATION ADDRESS (number and street, city, state, and ZIP code) 1. 2. 3. 4. 5. 6. 7. FEE SCHEDULE Kiddie - $144.00 Major - $144.00 Spectacular - $144.00 Ski Lift - $288.00 Rope Tow - $144.00 NAME OF SITE CONTACT PERSON & OPENING DATE CLOSING DATE ANNUAL INSPECTION TELEPHONE NUMBER (month, day, year) (month, day, year) (month, day, year)

Check here if paying by credit card.
Signature of owner / representative Date (month, day, year)

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CREDIT CARD PAYMENT This application must include payment of the permit fee of $ ____________. If paying by Visa or MasterCard, please complete the following information:
(amount) Full name on credit card Billing address (number and street, city, state, and ZIP code) Type of credit card Amount to be charged Telephone number

(

)

Visa
Account number

Master Card
Expiration date (month, day, year) CVV2 number (last three digits of the number in the signature block on the back of the card)

By signing this form, card member agrees to the obligations set forth by the Card Members Agreement with the card issuer.
Signature of card member Date signed (month, day, year)

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