Nps Form 10-114 - Special Use Permit - Hopewell Culture National Historic Park
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2NPS Form 10-114 (Rev. 01/2017)
National Park Service
SPECIAL USE PERMIT
Hopewell Culture National Historical Park
16062 State Route 104
Chillicothe, Ohio, 45601
740-774-1126
HOCU
Name
Park Alpha Code
Company/Organization
Type of Use
Street Address
Permit #
City
State
Zip Code
Country
Telephone Number
Cell Phone Number
Fax Number
Email Address
is hereby authorized to use the following described land or facilities in Hopewell Culture National Historical Park:
The area must be restored to its original condition at the end of the permit.
The permit begins at
am /
pm on
(mm/dd/yy).
(mm/dd/yy). The permit expires at
am /
pm on
SUMMARY OF PERMITTED ACTIVITY: (see attached sheets for additional information and conditions)
Person on site responsible for adherence to the terms and conditions of the permit (include contact information)
Authorizing legislation or other authority
Received
Amount
APPLICATION FEE
Not Required
$
Required
Amount
PERFORMANCE BOND
Not Required
$
Required
Amount
LIABILITY INSURANCE
Not Required
$
Required
Amount
COST RECOVERY
Not Required
$
Required
Amount
LOCATION FEE
Not Required
$
ISSUANCE of this permit is subject to the attached conditions. The undersigned hereby accepts this permit subject to the terms, covenants,
obligations, and reservations, expressed or implied herein.
:
Title:
Date
PERMITTEE Signature
:
Title: Superintendent
Date
Authorizing NPS Official
Title:
Date:
Authorizing NPS Official (additional, if required)
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