Application for Temporary Mooring Permit - Hawaii

This "Application for Temporary Mooring Permit" is a part of the paperwork released by the Hawaii Department of Land & Natural Resources specifically for Hawaii residents.

The latest fillable version of the document was released on July 1, 2011 and can be downloaded through the link below or found through the department's forms library.

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APPLICATION FOR
TEMPORARY MOORING PERMIT
Division of Boating and Ocean Recreation
Department of Land and Natural Resources, State of Hawaii
1. PERMIT INFORMATION
Requested Start Date:
Requested End Date:
OFFICE USE ONLY
/
/
/
/
Date Received:
Island (
) :
Hawaii
Kauai
Lanai
Maui
Molokai
Oahu
q
q
q
q
q
q
one
4
Location:
Received By:
Number of Persons Staying Aboard:
Shower Cards/Gate Keys:
Yes
No
q
q
2. APPLICANT INFORMATION
Name (Last):
(First):
(M.I.):
Suffix:
/
/
q
q
Date of Birth:
Gender:
Female
Male
Occupation:
Employer:
Phone (business):
Phone (home):
Phone (mobile):
Mailing Address:
Apt #:
Address Line 2:
Country:
City:
State:
Zip Code:
Residence Address:
Apt #:
Address Line 2:
Country:
City:
State:
Zip Code:
3. NAMES AND INFORMATION FOR PERSONS STAYING ON BOARD
Please provide the following information for each person staying on board the vessel.
Lastname
Firstname
Gender
Relationship*
Date of Birth
Contact Number(s)
(M/F)
*Relationship to Owner/Co-owner: Self, Parent, Spouse, Child, ICE (in case of emergency), Employee, Life Partner, Other (specify if “Other”).
4. VESSEL OWNER INFORMATION
check if same as Applicant
q
Business Name:
or
Owner
's Name (Last):
(First):
(M.I.):
Suffix:
Date of Birth:
Phone:
Co-owner
's Name (Last):
(First):
(M.I.):
Suffix:
Date of Birth:
Phone:
/
/
Temporary Mooring Permit, Revised: 07/2011
Page 1 of
2
APPLICATION FOR
TEMPORARY MOORING PERMIT
Division of Boating and Ocean Recreation
Department of Land and Natural Resources, State of Hawaii
1. PERMIT INFORMATION
Requested Start Date:
Requested End Date:
OFFICE USE ONLY
/
/
/
/
Date Received:
Island (
) :
Hawaii
Kauai
Lanai
Maui
Molokai
Oahu
q
q
q
q
q
q
one
4
Location:
Received By:
Number of Persons Staying Aboard:
Shower Cards/Gate Keys:
Yes
No
q
q
2. APPLICANT INFORMATION
Name (Last):
(First):
(M.I.):
Suffix:
/
/
q
q
Date of Birth:
Gender:
Female
Male
Occupation:
Employer:
Phone (business):
Phone (home):
Phone (mobile):
Mailing Address:
Apt #:
Address Line 2:
Country:
City:
State:
Zip Code:
Residence Address:
Apt #:
Address Line 2:
Country:
City:
State:
Zip Code:
3. NAMES AND INFORMATION FOR PERSONS STAYING ON BOARD
Please provide the following information for each person staying on board the vessel.
Lastname
Firstname
Gender
Relationship*
Date of Birth
Contact Number(s)
(M/F)
*Relationship to Owner/Co-owner: Self, Parent, Spouse, Child, ICE (in case of emergency), Employee, Life Partner, Other (specify if “Other”).
4. VESSEL OWNER INFORMATION
check if same as Applicant
q
Business Name:
or
Owner
's Name (Last):
(First):
(M.I.):
Suffix:
Date of Birth:
Phone:
Co-owner
's Name (Last):
(First):
(M.I.):
Suffix:
Date of Birth:
Phone:
/
/
Temporary Mooring Permit, Revised: 07/2011
Page 1 of
2
Division of Boating and Ocean Recreation
Department of Land and Natural Resources
State of Hawaii
APPLICATION FOR TEMPORARY MOORING PERMIT (
)
Continued
5. VESSEL INFORMATION
Vessel Name:
Port of Registry:
Registration
Coast Guard Documentation
None
q
q
q
Documentation Type:
Registration or Doc.#:
Expiration Date:
/
/
Hull Manufacturer:
Year Built:
Length Overall:
(feet)
(inches)
Hull ID#:
Number of Hulls:
Length Over Deck:
(feet)
(inches)
Hull Color:
Cabin Color:
Draft of Vessel:
(feet)
(inches)
Top Deck Color:
Trim Color:
Beam of Vessel:
(feet)
(inches)
6. VESSEL TYPE AND PROPULSION
q
q
q
q
q
Vessel Type ( one):
Open Motorboat
Motor Vessel (more than 65)
Sailing Vessel
Houseboat
Runabout
4
q
q
q
q
Auxilary Powered Sailing Vessel
Cabin Motorboat
Thrillcraft
Dinghy or Skiff
q
q
q
Barge
Platform
Other:
q
q
q
q
q
Principle Use ( one):
Pleasure
Charter Fishing
Commercial Fishing
Commercial Passenger
Charter Bare Boat
4
q
Dealer
q
Manufacturer
q
Charter Sail
q
Water Taxi
q
Other Commercial:
q
q
q
q
Primary Propulsion Type ( one):
Power
Sail
None
Other:
4
q
q
q
q
q
q
If Power: Engine Type(s) ( one):
Outboard
Inboard
Outboard / Inboard
Manual
None
Other:
4
Engine Manufacturer:
Horsepower:
Number of Engines:
q
q
q
q
q
q
If Sail:
Rigging Type:
Sloop
Schooner
Three-Masted Schooner
Four-Masted Schooner
Ketch
Brig
q
q
q
q
q
q
q
q
Brigantine
Barque
Barquentine
Fully Rigged Ship
Snow
Yawl
Cutter
Clipper
Auxiliary Propulsion for Sail:
q
q
q
q
Engine Type(s) ( one):
Outboard
Inboard
Outboard / Inboard
None
4
Engine Manufacturer:
Horsepower:
Number of Engines:
q
q
q
q
Fuel Type ( one):
Gasoline
Diesel
Electric
Other (specify):
4
7. AGREEMENT & SIGNATURE
I agree to comply with the provisions of the Hawaii
Administrative Rules as promulgated by the Division of
/
/
Boating and Ocean Recreation applicable to this permit.
Signature of Applicant
Date
Temporary Mooring Permit, Revised: 07/2011
Page 2 of
2

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