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T0: RALPH P. BOOTH, TOWN CIERK, TOWN OF SOUTHOLD
Application is hereby made, pursuant to the provisions of
the Penal Law, State of New York, Section 1894-a, for a permit to
diaplay Fireworks as hereafter age cified.
The display is to be sponsored by y/~yr~`Zi ~~~c ~~ ~.u
~~ , with principal office at ~ ,
New York, and will be held on , , 19~at
~( a~- d to
p J ~
4 ~~% it P.M.
oux'
The following persons are to be in charge of the actual
shooting of the fireworks:
NA
Mg AGE ~ERIENCE PHYSICAL CON
D
ITIO
N
~~
~~~~~~ ~
~/
~
Number and type of fireworks is as follows:
1 2 ~' fi O U rt/ -). S [` %, /fit ~ c ~ i
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.
Dated:
at % `/_ ~J New York
THE TRAVELERS
IIftje ~Grabelero ~fu~urauee (li;ompaup
~l)e ~rabelertt ~InDemuitp (~ompanp
"Phis is to certify that policies of insurance as described below have been issued to Che insured named below ~
and are in force at this time. If such policies are canceled or changed during the periods of coverage as stated
herein, in such a manner as to affect this certificate, written notice will be mailed to the party designated below for
- whom this certificate is issued.
1. Name and address of insured North Foi".k COUntry lu
S/S Main Road
Cutchogue, Suffolk Co. New York
2. Location of operations to which this certificate applies
Southold Suffolk Co. NY
3. Name and address of party to who this car ifi to i iss e~i
own of ~out~o'~d
~ Southold Suffolk Co. NY ~
~I. Coverages for which insurance is afforded Limits of Liability Policy Number PolleyPeriod*
Workmen's Compensation and Employ¢rs' Compensation-Statutory **
Liability in the state named in item R h¢r¢of
Bodily Injury Liability-except eutomobil¢ **
$ 1QQ,000 each person
--eluding Protective $ 3QQrOOO each accident
7-4-54
------ ------------------- -------------------- ---- -
ProperkyDamageLiability-except automobile - - -
- - ------ ------ - **- SLG 2 88
5949
t0
$ 25 t QQQ each accident -5"54 ~
eluding Protective
I $ aggregate
**
Bodily Injury Liability-eutomobil¢ $ each person
$ each accident
Property Demag¢ Liability-eutomobil¢ $ each accident
*Policy is effective and expires at 12:01 a.trt., standard time at the address of the named insured as stated herein.
**Absence of an entry in these spaces means that insurance is not afforded with respect to the coverages opposite
thereto.
Description of Operations:
Fireworks, etc. #326S
Liability for damage to property caused by ^ Blasting or Explosion, or ^ Collapse of or Structural Injury to
(Enter X in block aDDlicable)
any building or structure is excluded from operations classified as
The insurance afforded is subject to all of the terms of the policy applicable thereto.
This certificate is executed by The Travelers Insurance Company as respects insurance afforded by that com-
panyunder the policies designated above; it is executed by The Travelers Indemnity Company as respects insurance
afforded by that company under the policies designated above.
Mark W. Flanagan T AVELERS NSURANCE PANY
Branch Office R413r1>L --_--._ .,i~AVEL~IND~+IfVIT~,~OMPANY
6-25-54 em
65918 4-50 raxreo ix as.e.