NORTHERN VIRGINIA REGIONAL PARK AUTHORITY A Application for License for Non-Park Use
Name of Applicant (Licensee): ______
Address: ______
Phone: ______Fax: ______Email: ______
Name of Applicant’s Agent/Representative: ______
Address: ______
Phone: ______Fax: ______Email: ______
Name of Applicant’s Field Contact/Inspector: ______
Phone: ______Mobile: ______
Attach the following information/plans:
1. Project location (specific park and location within park).
2. Detailed description of proposed use, activity or facility.
3. Who proposed facility is intended to serve.
4. Individual, corporation or entity that will operate/maintain any improvements or facilities.
5. Detailed statement of need and justification for project and discussion of alternatives not on park property (or lack thereof) available to applicant. Applicants must demonstrate an absolute need for use of park land and lack of alternatives.
6. Anticipated impact on park lands, improvements or users resulting from proposed use or construction.
7. Description of any enhancement to park resulting from project.
8. Timing of construction.
9. Duration of proposed use (facility life).
10. Construction methods to be used, including type of equipment.
11. Proposed mitigating measures to minimize impact(s) on park land.
12. If utility or roadway, width of right of way required for construction and for maintenance.
13. One copy of detailed plans, cross sections, and profiles at a suitable scale that include the following:
a. Proposed facilities (type, quantity, size, materials, inner ducts, line capacity, casings, identification markers, and all other appurtenant facilities). Include distances to nearest roads and landmarks so that location can be precisely determined in the field. Only those facilities shown on the approved plans shall be allowed on park property.
b. Note: For crossings of the W&OD Trail, utilities must be bored at least 36" below grade and drainage swale inverts; bore and recovery pits must be shown outside the limits of park property; and utilities must be perpendicular to the trail and along roadways.
c. Park boundaries and adjacent properties.
d. Paved and gravel trails and other park facilities and infrastructure.
e. Limits of construction activity, including storage and staging and placement of vehicles and equipment.
f. Entire access route for installation and maintenance.
g. Locations of all safety features including warning signs (including symbol/message), safety fence, lights, cones, barrels, and flaggers.
h. Existing utilities and methods to locate them.
14. Maintenance of traffic plan for paved, gravel, and natural surface trails and park roads. Include related safety features and a schedule for installation and removal of detours.
15. Detailed vehicle and equipment list including type, quantity, size, loaded weight, rubber tire or tracked/cleated, and number of trips.
16. Detailed restoration plan, including a landscape plan if existing vegetation is to be removed or impacted. Plan must be specific and include species, size, and quantity of existing and replacement vegetation, methods to contain the limits of clearing and construction, and tree protection/preservation methods.
17. Drainage/erosion and sediment control plan, if applicable.
18. Any additional information the Authority may need to evaluate the proposed project.
CERTIFICATION: I hereby agree on behalf of the above named applicant that the applicant will promptly pay to the Northern Virginia Regional Park Authority all costs and expenses incurred by the Authority in connection with the administration of this application and any subsequent license or permit which may be approved, including, without limitation, costs and expenses associated with the processing and review of this application, planning and consultations involving modifications to the nature and scope of the applicant’s project, computation of fees and compensation, site inspections, preparation of agreements and related documents, negotiation, coordination with interested or affected third parties, construction plan review and approval, construction inspection, problem solving, restoration work, resolution of disputes, engaging and coordinating with outside consultants as required, and other activities related to applicant’s project.
Name of Authorized Representative of Applicant: ______
Title of Applicant’s Representative: ______
Signature of Applicant’s Representative: ______
Date: ______
Administration and inspection fee deposit amount will be determined after acceptance of a complete application and must be paid prior to further processing of the application. Use fee and construction bond payments will be required prior to construction.
Return to:
Northern Virginia Regional Park Authority
Land Manager
5400 Ox Road
Fairfax Station, VA 22039
703-352-5900
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