ࡱ>  @ )bjbj00 !RbRb(7TVaaaZbncV e<Bi(jijiijZk4Lk8 { RV ojjoo jii4M vvvorjiivovv&jid M9Faiqjl~Dc 0 #q#&VV#&X hklvRmmhkhkhk  V  $+>8)vV >8Michigan Department of Natural Resources Event Application/Permit to Use State Land This information is required under authority of Part 5 of Act 451 of 1994, as amended, MCL 324.501- 511 and the Rules for the Regulation of State Lands, R299.921 R299.932.DNR USE ONLYManagement UnitPermit Number APPLICANT: Please read all attachments before completing application. Submit completed application to local DNR office where permit is being sought. Application must be submitted at least sixty (60) days prior to proposed use. Attach additional information as needed to fully describe proposed use activity. Checks or money orders should be made payable to State of Michigan. Initial application fee of fifty dollars ($50.00) must be submitted with application.  Name of Applicant/Organization  FORMTEXT      Name of Contact Person  FORMTEXT      Address  FORMTEXT      Address  FORMTEXT      City, State, ZIP  FORMTEXT      City, State, ZIP  FORMTEXT      Telephone ( FORMTEXT      )  FORMTEXT      FAX ( FORMTEXT      )  FORMTEXT      Federal ID Number  FORMTEXT      Telephone ( FORMTEXT      )  FORMTEXT      FAX ( FORMTEXT      )  FORMTEXT      e-mail address  FORMTEXT      Proposed Event Location on State Land (Name of Trail or Department Facility or Legal Property Description, and Attach Map)  FORMTEXT      Duration - FORMCHECKBOX 1/2 Day or less FORMCHECKBOX 1 Day FORMCHECKBOX 2-3 Days FORMCHECKBOX 4-7 Days FORMCHECKBOX 8+ DaysWill Applicant charge a fee/donation for participation? FORMCHECKBOX No FORMCHECKBOX YesWill Event require use of parking lot/campground/access site? FORMCHECKBOX No FORMCHECKBOX Yes If Yes, explain:Will structures or equipment be placed on State Land? FORMCHECKBOX No FORMCHECKBOX Yes If Yes, explain:Will sound amplification equipment be used? FORMCHECKBOX No FORMCHECKBOX Yes If Yes, explain:Will food, beverages or other items be sold? FORMCHECKBOX No FORMCHECKBOX Yes If Yes, explain:Will alcohol be served or consumed?  FORMCHECKBOX No FORMCHECKBOX Yes If Yes, explain:Will Event require use of utilities (water, electric, sewer) ? FORMCHECKBOX No FORMCHECKBOX Yes If Yes, explain:Will Event be competitive? FORMCHECKBOX No FORMCHECKBOX Yes If Yes, indicate Length of Route and describe below:Length: FORMTEXT      Type of event: FORMCHECKBOX 4-Wheel Drive FORMCHECKBOX ATV FORMCHECKBOX Motorcycle FORMCHECKBOX Snowmobile FORMCHECKBOX Boating FORMCHECKBOX Fishing  FORMCHECKBOX Equestrian FORMCHECKBOX Field Trials FORMCHECKBOX Dog-related (other) FORMCHECKBOX Walking/Running FORMCHECKBOX Bicycle FORMCHECKBOX Skiing FORMCHECKBOX Adventure Race  FORMCHECKBOX Family FORMCHECKBOX Other (specify) FORMTEXT      Description of Proposed Type of Event (Attach additional information as needed to fully describe event activity.)  FORMTEXT      Date(s) of Proposed Use From:  FORMTEXT       To:  FORMTEXT      Weekend Use  FORMCHECKBOX Yes  FORMCHECKBOX NoTime of Event (if applicable)  FORMTEXT      No. of Participants/Users  FORMTEXT      No. of Recreational Units (Camping)  FORMTEXT      Safety Plan - A Safety Plan is normally required for events as stated in the attached Conditions.Name of person in charge of Safety Plan  FORMTEXT      Telephone ( FORMTEXT      )Safety Plan Attached  FORMCHECKBOX Yes  FORMCHECKBOX NoFire Plan - A Fire Plan is required for motorized events and may be required for other types of events, as stated in the attached Conditions.Name of person in charge of Fire Plan  FORMTEXT      Telephone ( FORMTEXT      )Safety Plan Attached  FORMCHECKBOX Yes  FORMCHECKBOX NoAPPLICANT: Read all pages and attachments before certification and signature.Applicant CertificationI certify that the information submitted herein, including all attachments, is accurate and complete and that I have read and understand and agree to abide by the requirements contained on all attachments, including liability insurance and performance bonding requirements. I have enclosed the required Application Fee. I understand that, if I have submitted a Review Fee that is not the correct amount, an additional fee must be paid prior to review of my application. I also understand that all remaining fees for the use of the State Land must be received by the Department within 14 days of notification of approval to the applicant or permissions may be considered void.Applicant/Authorized Representative - Print or TypeSignature DateFor DNR Use OnlyManagement UnitCountyPerformance Bond Type  FORMCHECKBOX Surety  FORMCHECKBOX CashAmount $Receipt No.Other Charges $Receipt No.Review Fee $Receipt No.Application Fee $Receipt No.Use Fee $Receipt No.Timber Consideration Fee $Receipt No.Insurance Aggregate Amount $Date Permit IssuedDate Permit ExpiresApplicant / Permit Number(  FORMTEXT       )Department Representative (please print)Telephone (with area code)E-mail AddressSignatureAddress FORMCHECKBOX  ADDITIONAL REQUIREMENTS: As contained in the attached Exhibit(s). Conditions and Requirements Permit shall be available for inspection when Permittee is operating on State-owned land. Permission for use shall expire on the date indicated, unless sooner terminated. Payment in the amount specified shall be made prior to use of land, or in installments as indicated. Permittee shall maintain the area under Permit in a clean and orderly condition. Requests for Permit renewals should be made to the Department thirty (30) days prior to the expiration date of this Permit. Such requests will be considered only when all stipulations in the original Permit have been complied with. The rights accruing under this Permit shall not be assigned or transferred without the written permission of the Department Representative. Permittee shall not commit, cause, or allow to be committed, any waste of, or injury to, said premises or any part thereof, nor use the same except for the purpose indicated. Temporary improvements may only be made if further authorized under the conditions of this Permit, or by separate written permission of the Department Representative. Improvements made by the Permittee on said premises and not removed within 30 days after cancellation or expiration of this Permit, and when such removal shall be requested by the Department, AT THE DEPARTMENTS OPTION, shall become attached and remain a part of the premises. The Department reserves the right to: dispose of any portion of the premises herein described during the term of this Permit. If possible, proper notice of sale or disposition will be given Permittee. However, failure to notify Permittee will not affect this right. lease said premises for exploration and production of any or all minerals, including coal, gas, oil, sand, gravel, etc. grant rights-of-way and easements of any kind and nature over and across said premises, and to grant or exercise all other rights and privileges of every kind and nature not herein specifically granted. Permittee and occupants are responsible for the payment of all utility bills including water, electricity, gas, etc. Permittee agrees to comply with all requirements herein, and, if for any reason Permittee violates or neglects to fulfill such requirements, this permission for use shall terminate and Permittee shall forfeit all rights and payments made hereunder. Should Permittee remain in possession of said premises after cancellation or expiration of this Permit, said Permittee shall be considered as tenant or tenants holding over without permission and may be evicted from said premises. Permittee shall comply with all applicable (including but not limited to all environmental) laws, regulations and codes and will obtain any necessary Permits in connection with its use of the Premises. Permittee shall reimburse the Department for any repairs to the Premises resulting from damage. Permittee shall report, in writing, to the Department Representative, all incidents related to the use of this Permit that result in personal injury, death, or property damage. Incidents resulting in personal injury, death, or property damage (estimated to exceed $300.00) must be reported to the Department Representative immediately by telephone or in person, followed by a written report. The Department shall have the right at all reasonable times during the term of this Permit to enter the premises for the purposes of making any inspections, repairs, additions or alterations as may be deemed appropriate by the Department for the preservation of the Premises. Permittee shall comply with the Elliot-Larsen Civil Rights Act, 1976 PA as amended, CML 37. 2101 et seq.; MSA 3.548 (101) et seq.; the Persons with Disabilities Civil Rights Act, 1976 PA 220, as amended MCL 37.1101; MSA 3.500 (101) et seq., and all other federal, state and local fair employment practices and equal opportunity laws and covenants that it shall not discriminate against any employee or applicant for employment, to be employed in the performance of this contract, with respect to his or her hire, tenure, terms, conditions or privileges of employment, or any matter directly or indirectly related to employment, because of his or her race, religion, color, national origin, age, sex, height, weight, marital status, or physical or mental disability that is unrelated to the individuals ability to perform the duties of a particular job or position. Permittee agrees to include in every subcontract entered into for the performance of this Permit, this covenant not to discriminate in employment. A breach of this covenant is a material breach of this Permit. Conditions and Requirements (contd) Permittee shall comply with the Employers Engaging in Unfair Labor Practices Act, 1980, PA 278, as amended, MCL 423.321 et seq., MSA 17.458 (21) et seq. There shall not be any disturbance to survey corners and associated witness trees. INSURANCE: Applicant shall furnish to the Department, prior to issuance of written permission, a policy of liability insurance which provides as follows: Names of Insured, the Applicant, its officers, employees, and agents; Coverage against all known and unknown hazards arising from the acts and omissions of the Applicant, its officers, employees, and agents; Coverage for Applicants contractually assumed obligation to indemnify and hold harmless the State of Michigan, its departments, officers, employees and agents; A term of coverage for not less than the term of use; Liability insurance coverage with respect to personal injury, death, and property damage to the limits described in the Guidelines for Liability Insurance Requirements for User Groups; That the policy will not be cancelled, or its provisions modified or deleted, unless and until the insurer first sends thirty (30) days written notice to the Department representative shown on permit. 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hx$1$Ifa$gdKP`+<q<<==>U?)VW$ $Ifa$gdy}  $Ifgdqpxgd & F35x1$]5gd/v; & F3 5P1$]5gdKP` & F2 :H<1$]:^H`gdKP` Permit. As soon as security for the performance of the terms and conditions of the Permit or the settlement of claims incident thereto is no longer necessary, deposits in lieu of surety or cash bond will be returned to the Applicant/Permittee. CAMPING OUTSIDE A DESIGNATED CAMPGROUND: If camping involves five or more sites (thirty-two or more individuals or five or more recreational units), a Temporary Campground Permit must be obtained from the local county health department. Copies of the Permit must be provided to the Department before use. FOREST FIRES: Permittee shall take all reasonable precautions to prevent and suppress forest fires. DAMAGES: The Permittee shall be held liable for any damages caused by operations under this Permit which may arise to forest growth, fences, crops, buildings or other improvements on State-owned property. This shall be as determined by the Department Representative. ADDITIONAL REQUIREMENTS: Permittee shall review any additional site specific or use specific requirements (Exhibits) provided by the Department and ascertain agreement by Permittees authorized representatives signature and date on each Exhibit. This Permit shall not be effective until such agreement is made. LIABILITY: Permittee hereby releases, waives, discharges and covenants not to sue the State of Michigan, its departments, officers, employees and agents, from any and all liability to Permittee, its officers, employees and agents, for all losses, injury, death or damage, and any claims or demands therefore thereto, on account of injury to person or property, or resulting in death of Permittee, its officers, employees or agents, in reference to the activities authorized by this Permit. INDEMNIFICATION: Permittee hereby covenants and agrees to indemnify and save harmless, the State of Michigan, its departments, officers, employees and agents, from any and all claims and demands, for all loss, injury, death or damage, that any person or entity may have or make, in any manner, arising out of any occurrence related to (1) issuance of this Permit; (2) the activities authorized by this Permit; and (3) the use or occupancy of the premises which are the subject of this Permit by the Permittee, its employees, contractors, or its authorized representatives. PENALTY NOTICE: Non-compliance with terms of the written permission, if granted, will be basis for forfeiture of some or all of the performance bond, termination of the written permission, and denial of future use applications. Permissions issued under this policy do not exempt the Applicant/User from complying with existing statutes. 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