OFFICIAL USE ONLY Special Event/Use Name:

Special Use Application $100 A Special Use Permit is required for conducting any of the following in Jackson Demonstration State Forest:

➢ Any organized activity or event which: • will be advertised or noticed in any publication, poster, electronic media, or flyer, or • requests or requires a fee for participation, or • meets any of the described Special Use categories (events, ongoing activities/programs, activities outside State Forest

standards, filming, educational events) Please submit this completed application including attached map of your proposed route or use area (TYPE WRITTEN PREFERRED)

In person or by mail to: Jackson Demonstration State Forest 802 N Main St. Fort Bragg, CA 95437

Please note: The submittal of a Special Use Application and payment of $100 application fee is a request for a Special Use Permit for your event or activity and does not constitute a permit or approval for your event or activity. Upon approval of your application, permit requirements must be completed in order to proceed with the event or activity. Event fees are based upon number of participants/days and are non-refundable and permit is not transferable to a third party; rescheduling fee is $150. Minor Special Use Applications (i.e. events/activities one day and/or less with fewer than 75 participants) must be submitted at least 30 days in advance of event or activity and may be submitted up to 1 year prior. Major Special Use Applications (i.e. events/activities 2 or more days and/or more than 75 participants) have an annual deadline of March 1st of the year of the proposed event. Applications must be submitted annually for ongoing activities or programs. A maximum of two SUP shall be granted to an individual, group, or organization permittee per year. If you have any questions, please call (707) 964-5674 or visit our website Welcome to Jackson or www.fire.ca.gov. Application fee is nonrefundable.

APPLICANT INFORMATION Contact: Name / Title

Date of Request

Organization

Address City/State/Zip Code

Day Phone Cell Phone Fax Number

Email Address Website

Sponsor contact (Association, Group, etc.) if different from above:

Type of Event/Activity with anticipated headquarters location (Description):

Event/Activity Name:

Event/Activity Dates and Hours

Maximum Number of People expected to attend at one time: Total: Participants: Spectators: Staff:

Will Participants be camping?

Will a fee be requested or required for participation? YES NO

Is this a competitive event/activity? YES NO

Event/Activity shall not be advertised prior to written approval from JDSF. Any advertising after approval shall reference “Jackson Demonstration State Forest”. How is the event/activity going to be advertised? Please provide information on websites, publications, electronic media, flyers, etc.

What is the connection between your event or activity and the benefits to the State Forest? (Please be specific and provide as much detail as possible).

Please provide a general timeline of your event/activity:

A Special Use Permit is for non-exclusive use of the area designated in the permit. Will the event/activity require restricting access to other forest users for safety reasons? If so, please provide details concerning trails, trail segments, time frames, etc.

Please list any equipment or supplies that you would like to bring in for your event/activity:

The State of California shall not be held responsible for personal injury or property damage arising from the holding of your event or activity.

Upon approval of your application, you will need to obtain a comprehensive general liability insurance policy in which the State of California is a named insured. A copy of the insurance policy will need to be submitted to the Forest Manager at least seven (7) days prior to the event start date. The Permittee and their comprehensive general liability insurance policy will need to: (a) have a minimum limit of $1,000,000 per occurrence and a $2,000,000 aggregate; personal liability of $1,000,000 for athletic participant; liability for products – comp/op aggregate of $1,000,000; fire damage liability of $50,000; (b) maintain in full force and affect a policy of Workers Compensation Insurance covering all employees; (c) prevent participation in the event by persons who are not covered by the insurance; (d) policy shall be underwritten to the satisfaction of the State and shall contain this special endorsement “State of California, its officers, employees and servants are included as additional insured only insofar as operations under this special use permit are concerned; The insurer will not cancel or reduce the insured’s coverage during the period that this permit is in effect or without 30 days prior written notice, whichever is shorter, to State.” Upon approval of your application, you may be required to provide two (2) or more certified medical responders (i.e. wilderness first responders, emergency first responders or EMTs), depending on the event, and/or one (1) or more portable toilets. Please see the attached map of the forest. The route of the event, or area of use, must be shown on an acceptable map and submitted along with this application. The route or area of use must be approved by the State. Clean-up will be required within 24 hours following the event and covers all areas utilized for the event, including: complete inspection of parking area, eating areas, staging areas, trail route rest stops, etc., and removal of trash, portable toilets, all access and route signs, flagging and markers.

The State requires user fees for Special Use Events (ref AB 2351 Chesbro):

SPECIAL EVENT FEE SCHEDULE

Number of Days of Event # of Participants 1 2 3 4 5 6 7 8 9 10 0-50 $200 $400 $600 $800 $1000 $1200 $1400 $1600 $1800 $2000 51-100 $400 $600 $800 $1000 $1200 $1400 $1600 $1800 101-150 $800 $1000 $1200 $1400 $1800 $2000 151-200 $1200 $1600 $2000 $2400 201-250 $1600 $2000 251-300 $2000 $2400 301-400 maximum $3000 $3600

I certify that the information contained in the application is accurate and that any permits required by state or federal law will be obtained before commencing event or activity.

Signature of Responsible Party Date

Jackson Demonstration State Forest Special Conditions: *Date Received by JDSF: *Type of Requested Use:

Jackson Demonstration State Forest Acceptance: 1) Event 2) Ongoing Activity/Program

3) Activity/Program outside State Forest standard 4) Filming 5) Education

Rev. 10/19

OFFICIAL USE *Accept application for review *Return application to Applicant

*Reasons:

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General Location Map

JDSF Property Boundary

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