HomeMy WebLinkAboutIndian Neck Residents
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CERTIFICATE OF INSURANCE
This is to Certify, that policies in the name o£
L'dward Beauchamp
(Name of Insured)
7.lI Hampton Courts Port Washi.~ton~ Tvew York
(Street and Number( (City or Town) (State(
are in force at the date hereof, as follows-
POLICY LIMITS OF LIABILITY
KIND OF POLICY POLICY NO. PERIOD
Bodily Injury
Property Damage
Provided by Workmen's
A- Workmen's Eff. Compensation Law State of Nil
Compensation Exp.
B- Manufacturers' or Eff. Each person $ Each accident $
Contractors' Liability Exp. Each accident $ Aggregate $
C -Owners, Landlords Eff. Each person $ Each accident $
and Tenants' Liability Exp. Each accident $
D -Owners' or Contractors' Eff. Each person $ Each accident $
Protective Liability Exp. Each accident $ Aggregate $
E- Scheduled Eff. Each person $ Each accident $
General Liability Exp. Each accident $ Aggregate $
F- Automobile
Liability
(1) Owned Vehicles
(2) Hired Vehicles Eff. Each person $ Each accident $
Exo. Each accident $
(37 Other Non-owned
Vehicles
G-Comprehensive Eff. Each person $ Each accident $
Liability
(I) Automobile Exp. Each accident $
(2) ](¢~`I,~[ Eff. ,/25/63 Each person $ 50y000a Each accident $ 50000,
P~tSONAL 296008 Exp. !x/25/66 Each accident $ 50000.
Aggregate $ 50,000. Aggregate $ 50,000.
Eff. Each person $ Each accident $
(3) General-Automobile Exp. Each accident $
Aggregate $ Aggregate $
and cover, in accordance with the policy terms, lOCatlOn covered Indian Neck Laney Peconic~ Suffolk New
York. This certificate of insurance is conditioned to comply to(Subdivision 5 0£ Section
1891-a) (Penal Law of the State o£ N.Y. )
Certificate issued to Torm O£ SOUthold
ar Southold, Su£folk~ N.Y.
In the event of any material change in or cancelation of said policies the undersigned company will notify the party to whom this certificate
is issued of such change or cancelation.
HONIu INllEI~IIVITY CO.
HU/L/'~S. & -ST'ECTER~ INC.
ilk" ~ -~Ly-GL,~:------------ .............
Dated 6/ZS/65 -11J ~~
GU6469a IEd. 5-54i ~NiFOAM Pa~H,~N~ a s~oPC. oi~.
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TO: ALBERT W, RICHMONDt TOWN CLERKS TOWN OF SODTHOLD
~.
APPLICATION IS HEREBY MADE pursuant to the provisions of
Section 1894~a of the Penal Law of the State of New Yorkt for a permit
to display fireworks as hereinafter specified;
The display is to be sponsored by ~ j ~~~ ~, r I(;~ ~~~ A~ 0.1t;,C~
with principal office at °
New Yorks and will be held ant k"i) P ~~'(J I
(day (mono
at P.M..
(hour} 0 (Z (_ [7 U ~'t-{{ Q ~ ~'Ut,=`(
`IF R~t1~y
196
The following persons are to be in charge of the actual
shooting of the fireworks:
NAME AGE EXPERIENCE PHYSICAL CONDITION
lU /~,9..~ ~''. l?,L A tl Chi A K ~ ~ fr ~I ~ A U:^ E`I.c PrLl.~~t.1 ~,
~og~ ~i G. `Y{Zu u~ ~ l ~ ~`~1~a2 ~~ Ce;`l t,t~~t~°
~Aui, w, ~IhNs ~ ~~~ ~~l-i.enr~
~551s~--~ ~ ~~.~ 9R, 7~F '~Aucriy~Y~ .,q-~D HER, ~~i ~"off P.~~e~{~.1~UB
Number and type of fireworks is as follows;
L~
CO U ~~ wA~
The fireworks will be stored in a covered truck prior to
the shooting on the grounds.
Attached hereto and made apart hereof is a diagram of the
grounds on which the display is to be held. Also attached is the certif-
icate or policy of insurance coverage,
Dated ~z- ~' -~ ~ L~ ~
at .~C'-~~~~c-~ a New York.
Respectfully submitted
((npame/ of orgain~/'zation) /