ࡱ> %` Ⱦbjbjٕ >6. . . . ~ ~ ~  55586dv6 Od28LR8R8R8R8;>N;$r;uRwRwRwR=R@Z@4c$ehgXc~ C:" ;CCXc. . R8R8 dHHHCf. R8. 8R8uRHCuRHH:Ko. f LR87 @܌Ί5D*IL 9M<d0OdSL.h#F2hLh~ L;6=HP?D@;;;XcXcUHj;;;OdCCCC *65 65 . . . . . .  (NPS Form 10-932) National Park Service (OMB No. 1024-0026) Boston National Historical Park (NEW 10/00) Boston, Massachusetts (Expires 3/31/2010) 617-242-5628 Application for Commercial Filming/Still Photography Permit Please supply the information requested below. Attach additional sheets, if necessary, to provide required information. Allow AT LEAST four (4) business days for processing. A non-refundable processing fee should accompany this application unless the requested use is an exercise of a First Amendment right. You will be notified of the disposition of the application and the necessary steps to secure your final permit. Your permit may require the payment of cost recovery charges, a location fee, and proof of liability insurance naming the United States as also insured. Applicant:Company:Social Security #:Tax ID #:Street/Address:Street/Address:City/State/Zip Code:City/State/Zip Code:Telephone #:Telephone #:Cell phone #:Cell phone #:Fax #:Fax #:E-mail:E-mail: Project name:Producer:Location manager:Photographer:Telephone #:Director:Cell phone #:Insurance company:E-mail: TYPE OF PROJECT: o Stills, editorial o Stills, advertising o stills, other o stock photo/video/film o Feature Film /TV Movie o TV Series/Pilot o Documentary/Travelogue o Commercial o Music Video o Infomercial o Industrial o Public Service Announcement o Other, explain ________________________________________________ Will there be sound recording o Yes o No Night work: o No o Yes, explain Detailed description of on-site activities Talent comprise anyone in front of the camera and includes, but is not limited to, actors, hosts, correspondents, presenters, park visitors, cooperators, volunteers, National Park Service and concessioner staff, etc. Do you intend to utilize talent? o Yes o No If yes, provide a full description of who they are and how they will be utilized:  LOCATION SCHEDULE: PRIVATE DATELOCATIONStart TimeEnd TimeInterior or ExteriorFILM STRIKE PREP# of cast & crew* o o o  o o o o o o o o o o o o o o o o o o *number in this column should include all individuals present at the location How will individuals with access to the site be identified? (Identification tags are recommended.) _____________________________________________________________________________________ Electrical needs, explain Generator: o No o Yes, size _______________ Lighting: o None o Reflectors only o Yes (explain) ____________________________________ _____________________________________________________________________________________ Road Use: Date/time: ________________________ o Closure requested o Running shots o Driving shots o Drive-bys o Tow shots o Drive-ups & Away o Wet down road o Camera/Equipment on Road Shoulder o Camera/Equipment on median o Other (explain) OPERATIONAL INFORMATION: Vehicles: Personal Cars _ Large Trucks _ Other Trucks Vans ______ Motor homes ________ Semi-Tractor Trailers _______ Camera Car Picture Cars Dressing Rooms _______ Other Vehicles (explain)_______________________________________________________________ Large or oversized vehicles may not be able to be accommodated or additional steps may need to be taken to ensure that no damage to park resource occurs. Vehicles or to be parked on or need access to park property (attach additional sheets if necessary): MAKEMODELCOLORSTATELICENSE PLATE # Base Camp location (attach diagram if necessary: _____________________________________________ CATERING INFORMATION Catering Co. Name Phone Number ___________________ On-site Manager _____________________________ Food License Information:____________________ Equipment: ____________________________________________________________________________ SPECIAL ACTIVITIES: Children: o None o Yes # of Children Age Range ___________________________ Animals: o None o Yes (explain) Trainer Name: Phone #: ____________________________ Aircraft: o No o Yes (explain) Special Effects: (identify) Effects Technician Name: Phone # ____________________________ License # (if applicable) Permit # (if applicable) ________________ Stunts: (explain) Coordinator____________________________________Phone #_____________________________ Any other unusual or hazardous activities? explain  Are you familiar with/ have you visited the requested area?  FORMCHECKBOX Y  FORMCHECKBOX N Have your obtained a permit from the National Park Service in the past?  FORMCHECKBOX Y  FORMCHECKBOX N (If yes, provide a list of permit dates and locations on a separate page.) Do you plan to advertise or issue a press release before the event?  FORMCHECKBOX Y  FORMCHECKBOX N ATTACH ADDITIONAL PAGES FOR INFORMATION NEEDED TO EVALUATE YOUR PERMIT REQUEST INCLUDING: set construction, parking, sanitary facilities, crowd control, emergency medical plan, off-road activity, trail use, or use of any building and site clean up. Include a proposed Site Plan(s). CONTACTS: Person on location responsible for company's adherence to all terms & conditions of a Film Permit: Name: ________________________________ Title: _______________________ Phone: ____________ Person on location responsible for coordinating activities with the NPS: Name: ________________________________ Title: _______________________ Phone: ____________ Person at the company office to contact for follow up information and billing: Name: _______________________________Title: _________________________Phone: _____________ ********************************************************************************** I hereby state that the above information given is complete and correct, and that no false or misleading information or false statements have been given. All estimates are reliable to the best of my knowledge and I have the full authority to represent the applicant/production company and the project described above. Signature ______________________________ Title ______________________ Date ____________ Company Name _________________________________________________________ ********************************************************************************** Information provided will be used to determine whether a permit will be issued. Completed application must be accompanied by an application fee in the form of a cashiers check or money order in the amount of $___.00 made payable to National Park Service. Credit card payments may be accepted at some parks. Application and administrative charges are non-refundable. This completed application should be mailed to ___________________________________ at the Park address found on the first page of this application. Note that this is an application only, and does not serve as permission to conduct any use of the park. If your request is approved, a permit containing applicable terms and conditions will be sent to the person designated on the application. The permit must be signed by the responsible person and returned to the park prior to the event for final approval by the Park Superintendent. **************************************************************************** The above application form is provided with the understanding that parks will insert appropriate park names and addresses and the amount of the application fee as desired. Paperwork Reduction Act Statement: This information is being collected to allow the park manager to make a value judgment on whether or not to allow the requested use. All the applicable parts of the form must be completed. A Federal agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Estimated Burden Statement: Public reporting burden for this form is estimated to average 30 minutes per response including the time it takes to read, gather and maintain data, review instructions and complete the form. Direct comments regarding this burden estimate or any aspects of this form to the National Park Service, Special Park Uses Program Manager, 1849 C Street NW (2465), Washington, D.C. 20240 Special Events Film Application (Short/Long Form) Addendum 2008 Insurance Policy All permittees are responsible for supplying insurance that covers the group that the permittee plans to host as follows: If services are provided at , are performed by any individual or entity outside of the government, such a person or group must: Procure public and employee liability insurance from a responsible company or companies with a minimum limitation of $1,000,000 per person for any one claim, and an aggregated limitation of $3,000,000 for any number of claims arising from any one incident. The policies shall name the United States of America as an additional insured, shall specify that the insured shall have no right of subrogation against the United States for payments of any premiums or deductibles due there under, and shall specify that the insurance shall be assumed by, be for the account of, and be at the insureds sole risk. Prior to beginning the requested event, a copy of such certificate of such insurance coverage must be provided by the permitee. The permit cannot be issued unless the United States of America is listed as additionally insured. List as: United States of America Department of Interior Boston National Historical Park Charlestown Navy Yard Boston, MA 02129 Alcohol Policy: Serving of alcohol must be accompanied by a copy of certificate of insurance covering liability to serve alcohol. Alcohol is to be served by a qualified bartender. NO CASH BAR ALLOWED. Alcohol shall not be stored on park property at any time other than during the time indicated on the permit. Group Policy: For each group of 150 attendees, an additional fee of $48.00 per hour is required for an on duty Law Enforcement Ranger(s). 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This cost is to cover various duties that are associated with security during each event. Note: If the original number of attendees is less than 150, but increases to more than 150, or the original number of attendees is more than 150, but decreases to less than 150, seven days notice must be given to the Special Events Office. This would allow time to scheduled or cancel the services of a Law Enforcement Ranger or Rangers. Seven days notification must also be given if the time requested for the on duty ranger changes. These policies and procedures are established under the title 36 Code of Federal Regulations. The Special Events Policy for the Boston National Historical Park and its sites is subject to change. Food will be served: [ ] Yes [ ] No Name of Caterer_______________ Phone #:____________ Alcohol will be served: [ ] Yes [ ] No Person or Company Covering Liability: __________________ Phone #: _____________________ Special Requests: [Please refer to Rules and Conditions in the application package]* Note: Please be advised that permittee may be accessed a charge for use of equipment, supplies or other special requests. Permittee is responsible for set-up, catering and clean-up. Open flame ( i.e. sterno) is not allowed in any of the buildings. Smoking is not permitted in any buildings. All areas must be left in substantially the same condition as they were found. Trash must be removed immediately as well as any additional equipment, goods or furnishings brought into the facility. If the facility is not left in substantially the same condition as it was found, the permittee may be accessed a charge for cleaning. COSTS: Please submit a check or money order for $50.00 with the application to cover the cost of processing the application. Make the check or money order payable to BOSTON NATIONAL HISTORICAL PARK. In addition you may be accessed charges for personnel, equipment use, special requests and other costs recoverable by the park under 16 U.S.C. 3a. ADDITIONAL CONDITIONS: I Agree That: My function will not interfere with normal visitor activities I understand and will comply with all conditions in the Use Conditions Sheet. I will follow all additional conditions imposed by the National Park Service and its Agents. 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