Form 10-114

Rev. DEC. 99 Page 1 of

**UNITED STATES DEPARTMENT OF THE INTERIOR**

National Park Service

**Special Use Permit**

Name of Use Date Permit Reviewed 20

Reviewed 20

Reviewed 20

Expires 20

Long Term Permit \# \_ \_ \_ \_ \_ \_ \_ \_ \_ \_ \_ \_ \_ \_ \_

Region Park Type No. \#

Short Term

Name of Area

of

Name or Permittee Address Phone

is hereby authorized during the period from (Time day Month 20 ),
through (Time

day Month 20 ), to use the following described land or facilities in the
above named area:

For the purpose(s) of:

Authorizing legislation or other authority (RE - DO-53):

NEPA Compliance: CATEGORICALLY EXCLUDED EA/FONSI EIS OTHER APPROVED
PLANS

PERFORMANCE BOND: Required Not Required Amount \$

LIABILITY INSURANCE: Required Not Required Amount \$

ISSUANCE of this permit is subject to the conditions on the reverse
hereof and appended pages and when appropriate to the payment to the
U.S. Dept. of the Interior, National Park Service of the sum of \$

The undersigned hereby accepts this permit subject to the terms,
covenants, obligations, and reservations, expressed or implied herein.

PERMITTEE

Signature Date

Authorizing Official ,

Signature Superintendent Date

Additional Authorizing Official ,

(if Required) Signature Title Date

**CONDITIONS OF THIS PERMIT**

**1. The permittee shall exercise this privilege subject to the
supervision of the Superintendent, and shall comply with all applicable
laws and regulations of the area.**

**2. Damages - The permittee shall pay the United States for any damage
resulting from this use which would not reasonably be inherent in the
use which the permittee is authorized to make of the land described in
this permit.**

**3. Benefit - Neither Members of, nor Delegates to Congress, or
Resident Commissioners shall be admitted to any share or part of this
permit or derive, either directly or indirectly, any pecuniary benefits
to arise therefrom: Provided, however, that nothing herein contained
shall be construed to extend to any incorporated company, if the permit
be for the benefit of such corporation.**

**4. Assignment - This permit may not be transferred or assigned without
the consent of the Superintendent, in writing.**

**5. Revocation - This permit may be terminated upon breach of any of
the conditions herein or at the discretion of the Superintendent.**

**6. The permittee is prohibited from giving false information; to do so
will be considered a breach of conditions and be grounds for revocation
\[Re: 36 CFR 2.32(a)(4)\].**

**7. Permittee will comply with applicable public health and sanitation
standards and codes.**

**Instructions for Special Use Permit Form**

(Discard before issuing permit)

**1. This form may be used to permit either [LONG TERM]{.underline} (not
to exceed 5 yrs) or [SHORT TERM]{.underline} (not to exceed 1 yr) uses.
Check the appropriate space at the top of the form.**

**2. The permit number requires 14 digits, designed for computerization.
The first 4 digits represent the Region symbol or may reflect the
purpose of the permit (FILM, EVNT etc.). The next 4 digits represent the
park area, the next 4 digits the type of permit (see code below), and
the last three the sequential number of the permit e.g. \# RMR GRTE 1100
105, a stock driving or trailing permit.**

**3. Note that uses addressed in 36 CFR are identified by the first two
or three numbers of the applicable regulation as the first part of the
\"type of use\" code.**

**4. If a performance or resource protection/clean up bond is required
so indicate along with amount.**

**5. Generally the NPS will recover all costs associated with issuing a
special use permit. (See Chapter 10 of Reference Manual 53). If no fee
is appropriate, insert [WAIVED]{.underline} in the appropriate block.**

**6. Park areas will append any [ADDITIONAL CONDITIONS]{.underline},
local instructions and applications.**

**7. A [LONG TERM]{.underline} designation is appropriate for the
following type of uses (list is not all inclusive):**

**[Code]{.underline} [Type of Use]{.underline} [Code]{.underline} [Type
of Use]{.underline}**

**1000 Agricultural (Gen) 5100 Advertisements**

**1100 Stock Driving or Trailing 5200 Alcoholic Beverages**

**1200 Stock Watering Dev. 5300 Business Operations**

**1300 Stock Corrals & Loading Chutes 5600 Commercial Vehicles**

**2600 Grazing/Pasturing Livestock 5610 Chemical Storage Bins**

**2610 Residing in Park 6000 Other**

**8. A [SHORT TERM]{.underline} designation is appropriate for the
following types of uses (list is not inclusive):**

**[Code]{.underline} [Type of Use]{.underline} [Code]{.underline} [Type
of Use]{.underline}**

**1100 Stock Driving or Trailing 4110 Load, Weight, Length, Width
Limitations**

**1300 Trail Rides 5100 Advertisements (5.1)**

**2170 Air Delivery 5101 Eating, Drinking, and Lodging**

**2171 Salvage of Downed Aircraft 5200 Alcoholic Beverages**

**2173 Hang Gliding, Ballooning, 5300 Business Operations**

**Ultralights, & Parachuting 5400 Commercial Passenger-Carrying Motor**

**2380 Explosives, Fireworks Vehicle**

**2400 Weapons, Traps, and Nets 5500 Commercial Photography**

**2410 Transport Game 5600 Commercial Vehicles**

**2500 Research Specimens(2.5) 5700 Construction**

**2501 Special Events 6000 Military Activities**

**2510 Public Assembly 7000 Climbing**

**2520 Sell/Distribute Printed Material 7100 Caving**

**2620 Scatter Human Ashes 8000 Gate Key**

**3300 Vessels/Boat Use 9500 Other**