Form 2920-1 - Land Use Application And Permit Page 2
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1
2
3PERMIT
Permit Number
Permission is hereby granted to
of
to use the following described lands:
TOWNSHIP
RANGE
SECTION
SUBDIVISION
Meridian
State
County
Acres
(number)
for the purpose of
and subject to the following conditions:
is issued for the period specified below. It is revocable
1. This permit
by this permit or
annually, as rental or
,
$
at the discretion of the BLM, at any time upon notice. This
such other sum as may be required if a rental adjustment is made.
permit is subject to valid adverse claims heretofore or hereafter
10. Use or occupancy of land under this permit will commence within
acquired.
months fromdate hereof and must be exercised at least
2. This permit is subject to all applicable provisions of the regulations
days each year.
(43 CFR 2920) which are made a part hereof.
11.
Permittee must take all reasonable precautions to prevent and suppress
3. This permit may not be assigned without prior approval of the
or in
forest, brush, and grass fires and prevent pollution of waters on
BLM.
the vicinity of the lands.
4. Permittee must not enclose roads or trails commonly in public use.
12. Permittee must not cut any timber on the lands or remove other
5. Authorized representatives of the Department of the Interior, other
resources from the land without prior written permission from the
Federal agencies, and State and local law officials will at all times
BLM. Such permission may be conditioned by a requirement
have the right to enter the premises on official business.
to pay fair market value for the timber or other resources.
6. Permittee must pay the United States for any damage to its property
13. Permittee agrees to have the serial number of this permit marked or
resulting from the use.
or
painted on each advertising display or other facility erected
7. Permittee must notify the BLM of address change
maintained under the authority of such permit.
immediately.
14. This permit is subject to the provisions of Executive Order No. 11246
8. Permittee must observe all Federal, State, and local laws and
of September
as amended, which sets forth the Equal
24, 1965,
regulations applicable to the premises and to erection or
Opportunity clauses.
copy of this order may be obtained from the
maintenance of signs or advertising displays including the
A
BLM.
regulations for the protection of game birds and game animals, and
must keep the premises in a neat, orderly, and sanitary condition.
15. Permittee acknowledges, by signing below, that he/she knows,
9. Permittee must pay the BLM, in advance, the lump sum
of
understands and accepts the terms and conditions under which this
permit is issued.
for the period of use authorized
$
Special conditions (attach additional sheets, if necessary)
16.
Permit issued for period
(Permittee)
From
(BLM)
To
(Title)
(Date)
INSTRUCTIONS
1. Submit, in duplicate, to any local office of the Bureau of Land
a (Notice of Realty Action) has been waived by the BLM.
Management having jurisdiction of the lands.
3. Costs of processing the application must be paid by the applicant
2. Applications for Land Use Permits will not be accepted unless a
in advance.
notification of the availability of the land for non-BLM use (Notice o f
has been published in the Federal Register and for 3
4
Realty Action)
The BLM may require additional information to process
.
weeks thereafter in a newspaper of general circulation.
This
an application.
Processing will be deferred until the required
provision does not apply in those situations where the publication of
information is furnished by the applicant.
(Continued on page 3)
(Form 2920-1, Page 2)
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