HARBORMASTER / COASTAL NATURAL RESOURCES

Duxbury, Massachu= setts

Donald C. Beers, III

Harbormas= ter

Jake B. Emerson &= nbsp; &nbs= p; &= nbsp; = = &nb= sp; = Michael B. Pforr

= = Executive Officer = &nb= sp; = &nb= sp; = = &nb= sp; Operations Officer

APPLICATION FOR A PRIVATE FUNCTION ON DUXBURY BEACH

PERMIT RE= QUIRES FIVE BUSINESS DAYS NOTICE

NAME: __________________________________= ____ FILING DATE: _____/_____/_____ =

ADDRESS: ___________________________________ DAYTIME PHONE: ______________=

CITY/TOWN: _________________________________ STATE: _____ ZIP CODE: _________

BEACH STIC= KER TYPE(S): STICK= ER PERMIT NUMBER: __________

&= nbsp; NUMBER OF VEHICLES: ______ DO THEY<= /span> ALL HAVE PERMITS? Y / N<= /o:p>

&= nbsp; &nbs= p; NUMBER OF RESIDENT 2WD = ______

&= nbsp; &nbs= p; NUMBER OF RESIDENT 4WD = ______

&nbs= p; &= nbsp; NUMBER OF NON-RES.&nb= sp; 4WD ______

DATE REQUESTED: _____/_____/_____ TIME REQUESTED: FROM ______ TO ______

NUMBER OF PEOPLE TO ATTEND: ________= _ AGE OF GUESTS: _________________

PURPOSE OF FUNCTION: ________________= ______________________________________

______________________________________________________________________= ___________________________________________________________________________= ___________

WHAT EQUIPMENT DO YOU = PLAN TO BRING? (I.E. T= ENT, MUSIC, VOLLEYBALL, CHEMICAL TOILET, ETC…):____________________________________________________ ___________________________________________________________________________= ___________________________________________________________________________= ______

I hereby agree to abide by the beach regulations and to take responsibility f= or the activities of all my guests. I understand public consumption of alcohol is PROHIBITED on Duxbury Beach. I also agree to abide by the speci= al requirements listed above and to end the function as prescribed.=

___________________________________________ = _____/_____/_____

&= nbsp; = SIGNATURE OF APPLICANT &= nbsp; &nbs= p; &= nbsp; = DATE

-----------------------= ---------------------------------------------------------------------------= ----------------------------------------------------------------FOR DEPARTMENT USE ONLY

(This section is to filled out the Harbormaster/Coastal Natural Resource Departme= nt)

AREA TO BE USED: ___________________________________________________________

DATE: _____/_____/_____         TIME: FROM ___________= TO ___________

SPECIAL REQUIREMENTS: (I.E. CHEMICAL TOILETS, POLICE OFFICER, = REFUSE REMOVAL) = ____________________________________________________________________= ___________________________________________________________________________= _____________

        =    _____/_____/_____          =             &nb= sp;      __________________________________= __

   &nbs= p;           DATE APPROVED&nb= sp;            =             &nb= sp;            =             &nb= sp;          AUTHORIZING DEPARTMENT AGENT