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APPLICATION FOR A SPECIAL USE PERMIT

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NEW J
ERSEY DIVISION OF FISH AND WILDLIFE
BUREAU OF LAND MANAGEMENT
P.O. BOX 420 MAIL CODE 501-03
TRENTON, NEW JERSEY 08625-0420
APPLICATION FOR A SPECIAL USE PERMIT
APPLICANT INFORMATION
OFFICIAL USE ONLY
NAME OF APPLICANT
DATE RECEIVED
GROUP NAME
NUMBER OF PARTICIPANTS
TOTAL FEE
CHECK
N/A
STREET ADDRESS
APPROVED
DENIED
CITY
ZIP CODE
INITIALS
DATE
TELEPHONE NUMBER
EMAIL ADDRESS
INSURANCE REQUIRED
YES
NO
PERMIT INFORMATION
TYPE OF USE
SPECIFIC USE – (LIST TYPE(S) OF EQUIPMENT AND/OR FACILITIES TO BE USED) (attach additional sheets if necessary)
WILDLIFE MANAGEMENT AREA – (specify location/include maps)
APPLICATION DATE START DATE FOR PERMIT / ACTIVITY END DATE FOR PERMIT / ACTIVITY
INSURANCE INFORMATION
Permittee may be required to supply comprehensive general liability insurance as broad as the standard coverage form currently in use in the State of New Jersey
which shall not be circumscribed by any endorsements limiting the breadth of coverage including coverage for product liability, protection and indemnity, Permittee
owned or operated motor vehicles, broad form contractual liability and broad form liability damage endorsements against claims for bodily injury, death or property
damage in any manner growing out of or connected with any activity on the Premises conducted by Permittee, its employees, volunteers, agents, contractors,
subcontractors, consultants or any other person providing any service and performing any activity as part of Tenant's operations on the Premises. Limits of liability
shall not be less than One Million ($1,000,000.00) Dollars combined single limit per occurrence.
The S
tate of New Jersey, Department of Environmental Protection shall be named as an “Additional Insured.”
ALCOHOLIC BEVERAGES
No person or persons shall consume or have in possession or control any intoxicating beverage or any beverage containing alcohol while on any land or water area
under the control of the Division, except that organized groups may, with written permission or other authorization from the Division, possess or consume alcoholic
beverages on designated Wildlife Management Areas.
CAMPING, PICNICKING AND FIRES
Camping or picnicking is prohibited on all Division controlled areas, including State Wildlife Management Areas. “Camping” means any temporary shelter such as a
tent, trailer, recreation vehicle, sleeping bag, hut or other structure that a person or persons use as sleeping, resting, or living quarters. No person shall set or cause
to be set, start, build or maintain any fire on State Wildlife Management Areas without written permission of the Division.
REVOCATION
The Division may revoke any permit or other authorization issued hereunder for due cause or for violation of any provision set forth herein, whether or not
prosecution is brought as provided in N.J.S.A. 23:7-9.
PERMIT FEES
In Accordance with N.J.S.A. 13:1D-9 and N.J.S.A. 23:7-9, fees will be charged for the special use of Wildlife Management Areas through the issuance of Special Use
Permits. Fee amounts are specific to activity type.
Please Complete all fields outlined in red
StateofNewJersey–DepartmentofEnvironmentalProtection–DivisionofFish&
Wildlife
SpecialUse
Per
mit
TYPEOFUSE‐
AREA‐
SPECIFICUSEANDLOCATION‐
DURINGTHEPERIODFROM‐ TO
PERMITTEE/GROUPNAME‐
ADDRESS‐
CONTACTNAME TELEPHONE‐
Subjecttothefollowingtermsandconditions:
1. ThePermitteewillpayapermitfeeof$ fortheperiodcoveredbythispermit.Thisfeeisdue .
2. ThePermitteewillpayalltaxesorassessments,ifany,leviedagainstthepremisescoveredbythispermit.
3.Thispermitmaynotbeassigned,inwholeorinpart,toanyotherperson.Thepremisescoveredbythispermitare
solelyforthepersonaluseofthePermittee;nocommercialactivityisallowed.
4.ThePermitteewillkeepthepremisesandanystructuresonthemingoodorderandrepairanduponthetermination
ofthispermit,thepremisesshallbeleftinasgoodacondition as the same are now, reasonable wear and tear
excepted.
5. ThePermitteeshall,intheuseofthepremises,conformtoalllaws,ordersandregulationsofthefederal,Stateand
localgovernmentspertainingtothepremisesandthepermittee’suseofthepremises.Theselawsinclude,butarenot
limitedto,theState’slanduselawswhichareoverseenandpermittedbytheDepartment’sDivisionofLandUse
Regulation.Formoreinformation,gotohttp://www.state.nj.us/dep/landuse/.
6. Nosignsoradvertisementsofanydescriptionwillbepermittedtobepaintedorpostedonthepremisesotherthan
thoseapprovedinwritingbytheStateofNewJersey,DepartmentofEnvironmentalProtection,DivisionofFishand
Wildlife.
7.ThePermitteeagreestoabidebytherulesandregulationsoftheDepartmentofEnvironmentalProtectionnow
existingorhereafteradoptedconcerningtheuseofthepremisesandagreestocauseotherstoobeysuchrulesand
regulations.
8. ThepremisesshallbekeptneatandcleanandthePermitteewillathisorherownexpense,makesucharrangements
asmaybenecessarytoremoveordisposeofallgarbage,rubbishorotherwasteaccumulatedbythePermitteeonthe
premisesduetoPermittee’sactivities.
9. Permittee shall secure and maintain in force comprehensive general liability insurance as broad as the standard
coverage form currently in use in the State of New Jersey includingcoveragefor productliability, protectionand
indemnity.Broadformcontractualliabilityandbroadformliabilitydamageendorsementsagainstclaimsforbodily
injury, death or property damage growing out of or connected with activity on the premises conducted by
Permittee, its employees, volunteers, agents, contractors, subcontractors, consultants or other persons providing
serviceandperformingactivity as part of Permittee'sactivitieson the premises.Limitsofliabilityshallnotbeless
thanOneMillion($1,000,000.00)Dollarscombinedsinglelimitperoccurrence.
TheStateofNewJersey,DepartmentofEnvironmentalProtectionshallbenamedasan“AdditionalInsured.”
10. Permitteeshallalsoprocureandprovideproofofcoverage,priortoenteringthepremises,forthefollowingtypesof
insurance,asapplicable:
a. Workers’CompensationInsuranceapplicabletothelawsoftheStateofNewJerseyandEmployer’sLiability
Insurancewithlimitsnotlessthan:
$1,000,000BODILYINJURY,EACHOCCURRENCE
$1,000,000DISEASEEACHEMPLOYEE
$1,000,000DISEASEAGGREGATELIMIT
b. Automobileliabilityinsurancewhichshallbewrittentocoveranyautomobileusedbytheinsured.Limits
ofliabilityforbodilyandpropertydamageshallnotbelessthan$1millionperoccurrenceasacombined
singlelimit.
c. Anyotherinsuranceorbondsinthetypesandamountsadictatedonthepermitandasrequiredbythe
Department.
11. CoveragemustbewrittenwithalicensedinsurancecarrierauthorizedtodobusinessintheStateofNewJersey.
12. PermitteeshallprovidetheStateofNewJerseywithacurrentCertificateofInsurancepriortothecommitmentofthe
termevidencingcoverageandrenewalsthereofwhichmustcontaintheprovisionthattheinsuranceprovidedinthe
Certificateshallnotbecancelledforanyreasonexceptaftergivingthirtydayswrittennoticeto:
StateofNewJersey
Department
of
EnvironmentalProtection
Division
of
Fish
&
Wildlife
POBox
420
MailCode
501‐03
Trenton,NJ
08625‐0420
13. ThePermitteeshall,forthePermitteeandthePermittee’ssuccessorsandassigns,assumeallrisksandliabilitiesarising
outofthePermittee'suse,operation,andmaintenanceofthepremises , including any and all illnesses persons are or
may become afflicted with due to their presence at the permitted activity. The Permittee covenants to defend, protect,
indem
nify,andsaveharmlesstheDepartmentandherebyreleasesthe Department and each of its officers, agents,
employees,successors,andassigneesfromandagainstanyandallsuchliabilities,losses,damages,costs,expenses
(includingreasonableattorney'sfeesandexpenses),causesofaction,suits,claims,demands,orjudgmentsofeverynature
arisingfromorclaimedtoarise,inwholeorinpart,inanymanneroutof,beoccasionedby,orresultfromanyinjuryto,or
thedeath of, anyperson in or on,or any damage to property whichoccursin,on,oraboutthepremises,orinany
mannergrowingoutoforconnectedwiththeuse,nonuse,orconditionoftheprem
ises;violationofanyconditionof
thispermitbythePermittee,itsagents,employees,contractors,invitees(expressorimplied),oranyone
claimingby orthroughthePermittee;violation by the Permittee of any federal, State, or local law, ordinance, or
regulation affectingthepremises and/or the Permittee’ use thereof; or anyact,errororomissionbythePermittee,
itsagents, employees, contractors, invitees (express or implied), or anyone claimingbyorthroughthe
Permitteeinthe performance of this permit. This indemnification obligation is not limited by, but is in addition
to the insurance obligationscontainedinthispermit.
14. The Permitteewill not erect any structures or additions toexistingstructuresormakeanychangesinthenatural
conditionofthepremiseswithouttheapprovalinwritingoftheDepartmentofEnvironmentalProtection.
15. This permit will expire on the last day of the terms stated and may be renewed only upon the acceptance by the
Department of Environmental Protection of a new application in writing, upon payment of the permit fee and
submission of proof of public liability and property damage insurance coverage. The renewal application must be
madetwo(2)monthsbeforetheexpirationoftheoriginalpermit in order for the activities to continue without
interruption.
16. AuthorizedagentsoftheDepartmentofEnvironmentalProtectionwillatalltimeshavetherighttoenteruponthe
premisesforthepurposeofmakinginspections.
17. This permit may be revoked or modified if, in the judgment of the Department of Environmental Protection, such
actionwillbestservetheinterestsoftheStateofNewJersey.Suchrevocationwillbeeffectiveimmediatelyor
upon suchtermsastheDepartmentofEnvironmentalProtectiondeterminesintheDepartment’ssolediscretion.
18. IntheeventofrevocationormodificationsofthisSpecialUsePermitresultingfromactionsofthePermittee,the permit
feeoranypartthereofisnotrefundable.
19. Thispermitgrantsnoprivilegeotherthanthosewhicharesetforthherein.
20. ThePermitteeshallnotchargeanyfeeforuseofthepremisesbyanyindividual,group,entity,organization,etc. without
thewrittenapprovaloftheDepartment.
21. ThePermitteeshall,duringthetermofthispermit,promptlypaywhenduealltaxesand/orassessments,together with
interestandpenaltiesthereonthatarelevieduponorassessedbyanygovernmentbodybyreasonofthe Permittee’s use of
thepremises.ThePermitteeimmediatelyshallforwardanynoticeofsuchtaxpaymenttothe Departmentand any noticeof
assessment,taxbill,oranyothernotice,correspondenceordocumentrelatingtolocal propertytaxationof the premisesto
theDepartment.
22. ThePermitteeshallbesolelyresponsibleforsupervisionofthepermittedactivityaswellastheactivitiesofanyandall
contractors,subcontractors,agents,volunteers,andanyotherpersonsunderPermittee’scontrol.ThePermitteeshall
immediatelynotifytheDepartmentbycalling877‐WARN‐DEP(877‐927‐6337)ofanyandallincidentswhether resulting
ininjuryornot,violationsofthepermit,violationsofthelaw,oranyothersuchincidents.
23. ThePermitteeshallberesponsiblefortheprotectionofPermittee’spersonalproperty.TheDepartmentshallnotbe liable
tothePermitteeforanyloss,damage,ordestructionofthePermittee’spersonalproperty.
24. ThePermitteeshallnotabuse,mutilate,injure,remove,ordestroyanylivingplantwithoutthepermissionofthe Regional
Superintendent.Allabused,mutilated,injured,removed,ordestroyedplantsshallbereplacedperthe Regional
Superintendent’splanforrestoration.
25. ThePermitteeshallnotabuse,mutilate,injure,remove,ordestroyanylivinganimal.IfPermitteeabuses,mutilates,
injures,removes,ordestroysalivinganimal,Permitteeshallbesubjecttothefines,penalties,andpunishmentas allowed
bylaw.
26. ThePermitteeshallnotabuse,mutilate,injure,remove,ordestroyanystructureorphysicalfeature.IfPermittee abuses,
mutilates,injures,removes,ordestroysanystructureorphysicalfeature,Permitteeshallberesponsiblefor the fullcostof
repairingorreplacingsuchstructureorphysicalfeatureatPermittee’ssoleexpense.
27. ThePermitteeshallnotabuse,mutilate,injure,remove,ordestroythegroundoranylandwithoutthepermissionof the
RegionalSuperintendent.Anyabused,mutilated,injured,removed,ordestroyedgroundorlandshallberestored perthe
RegionalSuperintendent’splanforrestoration.
28. Any specimens collected under this permit, any components of any specimens (including but not limited to natural
organisms, enzymes or other bioactive molecules, genetic materials, or seeds), and research results derived from collected
specimens are to be used for scientific or educational purposes only, and may not be used for commercial or other
revenue-generating purposes unless the permittee has entered into a benefit sharing agreement with the NJ Department
of Environmental Protection, Office of Natural and Historic Resources (NJDEP).
29.
Date Signed

Permittee
RegionalSuperintendent
click to sign
signature
click to edit
click to sign
signature
click to edit
The Permittee shall be required to submit a COVID-19 Operation Plan to the Grantor identifying how the
permitted activity will comply with all applicable Executive Orders issued by Governor Murphy to
safeguard the health and welfare of the general public. Failure to comply with the approved COVID-19
Plan and applicable Executive Orders will result in the event being shut down immediately and all
attendees vacating the area. Please be advised due to the COVID pandemic, an event may still be
cancelled by the Department (Grantor). The COVID-19 Operation Plan shall become a part of and
condition for Special Use Permit approval by Grantee. The Permittee is subject to full compliance with
all applicable Executive Orders 107 through 165 (and any revisions to these Executive Orders) and all
new Executive Orders enacted to stem the spread of COVID-19 and impacting the operation of State
Wildlife Management Areas managed by the Division of Fish and Wildlife. The Permittee shall be
responsible to comply with all applicable Executive Order requirements, including but not limited to
wearing face masks, social distancing for Permittees, employees, volunteers, patrons and participants.
Permittee shall be solely responsible for providing all Personal Protective Equipment necessary for the
Permitted Activity and for cleaning, disinfecting equipment and Grantee improvements utilized in the
Permitted Activity. Copies of the Executive Orders may be found at https://nj.gov/infobank/
eo/056murphy/approved/eo_archive.html. For more guidelines from the Center for Disease Control
and Department of Health related to social distancing, cleaning and disinfection, visit https://
covid19.nj.gov/ and https://www.cdc.gov/coronavirus/2019-
ncov/downloads/php/CDC-Activities-Initiatives-for-COVID-19-Response.pdf.
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APPLICATION FOR A SPECIAL USE PERMIT

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Completed 13 May 2021

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