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Parks & Recreatiion

TOWN OF SOUTHAMPTON

DEPARTMENT OF PARKS & RECREATION ALLYN F. JACKSON Superintendent

TOWN OF SOUTHAMPTON PARKS AND RECREATIION DEPARTMENT SPECIIAL USE PERMIIT

( (

) PORTABLE STAGE ) COMMERCIAL PHOTOGRAPHY PERMIT

(

(SEE SECTION NO. 8) ) OTHER _______________________________

CHECK TYPE OF PERMIT REQUESTED

PLEASE PRINT

( ( ( (

) SPORTS FIELD RESERVATION ) MEETING ROOM ) GROUP PICNIC ) SPECIAL EVENT

________________________________ APPLICATION DATE

1. 2.

NAME OF PERSON FILING APPLICATION

______________________________________________

MAILING ADDRESS PHONE: HOME

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ BUSINESS FAX

3. 4. 5.

6. 7.

__________________ NAME OF ORGANIZATION OR COMPANY

_________________

_________________

_______________________________________________

FACILITY DESIRED (BE SPECIFIC) D A T E ( S ) R E Q U E S T E D _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ NUMBER OF PERSONS INVOLVED _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ T I M E ( S ) R E Q U E S T E D _ _ _ _ _ _ _ _ _ ____________________________________________________ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ W I L L A F E E B E C H A R G E D ? _ _ _ _ _ _ _ _ I F S O , H O W M U C H ? _ _ _ _ _ _ _ _ _ _ _ ____________________________________________________ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ H O W W I L L I T B E U S E D ? _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

8.

All applications for commercial photography shall include a letter outlining the following information: Subject and type of photography, proposed use, number in cast and crew, type of costumes, number of

vehicles, person in charge on site, insurance coverage.

9.

SPECIAL REQUIREMENTS

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

10. I have read the rules and regulations governing the use of Town property and agree that by my signature I, as well as the organization which I represent, will abide by them.

SIGNATURE

_______________________________________

RETURN TO:

6 NEWTOWN ROAD TEL. 631-728-8585

HAMPTON BAYS, NY 11946 FAX 728-8525

OFFICE USE ONLY

(

)

APPROVED

(

) DISAPPROVED

PERMIT NO.

_________

FEE REQUIRED____________________________

FEE PAID________________________________

INSURANCE REQUIRED (

) YES

(

) NO

AMOUNT

___________________________

COMMENTS

___________________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

_________________________ DATE

___________________________________________ STAFF SIGNATURE

(

) CUSTODIAN

(

) POLICE

(

) PARKS SECURITY

(

) OTHER

________________________

CC: (

) MAINTENANCE

(

) BEACH MANAGER

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