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TOWN OF SOUTHOLD
PERMIT FOR PUBLIC DISPLAY OF FIREWORKS
I, JUDITH T. TERRY, Town Clerk of the Town of Southold,
Suffolk County, New York, being an officer duly designated by
.the Town Board of the Town of Southold for this purpose, do hereby
:.GRANT TO ORIENT FIRS DEPARTMENT
!A PERMIT FOR THE PUBLIC DISPLAY OF FIREWORKS by said organization
'in accordance with the provisions of Section 405.00 of the Penal
Law of the State of New York, on July 4. 1984 at approx. 8:30 P.M.
'_Rain Date: July 7, 1984 at approx. 8:30 P.M.
~at the time and place se,t forth in the application therefor. ON
I~CONDITION THAT the bond (indemnity insurance) required shall
continue in full force and effect in favor of the Town of Southold,
and PROVIDED that the actual point at which the fireworks are to
be fired shall be at least two hundred feet from the nearest build-
ing, public highway or railroad or other means of travel, and at
,.least fifty feet from the nearest above ground telephone or tele-
graph line, tree or other overhead obstruction, that the audience
at such display shall be restrained behind lines at least one
.hundred and fifty, feet from the point at which the fireworks are
discharged and only persons in active charge of the display shall
be allowed inside these lines, that all fireworks that fire a
projectile shall be so set up that the projectile will go into the
air as nearby as possible in a vertical direction, unless such
fireworks are to be fired from the shore of a lake or other large
.body of water, then they may be directed in such manner that the
falling residue from the deflagration will fall into such lake or
,body of water, that any fireworks that remain unfired after the
display is concluded shall be immediately disposed of in a way
safe for the particular type of fireworks remaining, that no fire-
works display shall be held during any wind storm in which the
wind reaches a velocity of more than thirty miles per hour, that
all the persons in actual charge of firing the fireworks shall be
.over the age of eighteen years, competent and physically fit for
„the task, that there shall be at least two such operators constant-
!ly on duty during the discharge and that at least two sodaacid or
lother approved type fire extinguishers of at least two and one-
half gallons capacity each shall be kept at such widely separated
points as possible within the actual area of the display.
DATED: July 3, 1984
JUD T. TE , own C •1~-
Town of Southold, Suffo i County,
New York.
S E A L
THIS PERMIT IS NOT TRANSFERRABLE.
j ~ i L1:i.91[U 1a1.\ id:7:TIP: F
.r ~ .• . .-.-. •I . 41:1
- -
NAME AND ADDRESS OF AGENCY
Volunteer Firemen's Insurance COMPANIES AFFORDING COVERAGES
Services, Inc. GDM PANY
PO Box 1462 LETTER AInsurance Co. of North America
- - ---_-
York, PA 17405 ~
_._ __ _.-
NAME AND ADDRE 55 OF INSURED
Orient Fire District
Orchard St.
Orient, NY 11957
This is to certify that pl
of any contract or oth~
terms, exclusions and
CGM PANYI
of such policies.
LETTER TY PE OF IN SURANCE
A
GENERAL LIABILITY
COMPREHENSIVE FORM
^ PREM156-OPERATIONS
] EXPLOSION AND COLLAPSE
HAZARD
^ UNDERGROUND HAZARD
PRODUCT G/COMPLETED
O PFR ATIO NS HAZARU
^ CONTRACTUAL INSURANCE
BROAD FORM PROPERTY
DAMAGE
^ INDEPENDENT CONTRACTORS
^ PERSONAL IN JU RV
AUTOMOBILE LIABILITY
^ COM PRFH FNS NF FORM
^ OWNED
^ HIHEU
^ NoN owrvEn
EXCESS LIABILITY
^ UMBRELLA rO RM
^ OTHEH rH AN UMRRFL LA
IORM
and
EMPLOYERS' LIABILITY
OTHER
A Fire Legal
Liability
COMPANY
LETTER
COMPANY /~
^
LETTER V
COM PA NV D
LETTER
GPP DO 85 74 36 4
9~15~84
PROPERTY DAMAGE
BODILY INJU RV AND
PROPEFTV DAMAGE
COMBINED
,000,00
x1,000, ®O
,000,00
b b
PERSONAL INJURY
BO DILV INJU RV
(EACH PERSON)
BODILY INJURY
(EACH ACCIDENT)
PRO PFRTV DAM AGE
BoDILr INJUer AND
PROPERTY UAM AGF
CGMflINFD _.
RO DILV INJURY AND
PHO PERiV DAMAGE
COMBINED
~~~STATl/TORV~
x1,000,
b
b
8
b b
Orient Yacht Club & Orient
GPP DO 85 74 36 4 9~15~84 Wharf Co. - $75,000 Bldg.
vin nnn rr,n+o„+~_ __
DESCRIPnoN of oPERArIOrvsJLOCanonsTVEHICLEs
Cancellation: Should any of the above describ~d policies be cancelled before the expiration date thereof, the issuing com-
pany will endeavor to mail days written notice to the below named certificate holder, but failure to
mail such notice shall impose no obligation or liability of any kind upon the company.
NAMf AND ADDRESS OF CERTIFICATE f10LD ER_
Town of Southold
Southold, NY 11971
COMPANY E
LETTER
=,n issued to the insured named above and are in force at this time. Notwithstantlingsny requirement, term or condition
certificate may be issued or may pertain, the insurance afforded by [he policies described herein is subject to all the
Poucv ~ Limits of Liability in Thousa_n_ ds (600) _
POLICY NU MBER FX PIRATION DALE EACH
OCCURRENCE AGGREGATE
_ _- - _._ _. l.___ I I _ _
BODILY INJU RV I bl 1 OOO I
6~29~84
DATE ISSUED:
~ ~ AUTHOA~D REPRESENTATIVE
ACORD 25 (1~I9)
APPLICATION RECNVED
~Jl1t~ 2 81984
T0: JUDITH T. TERRY, TOWN-CLERK, TOWN OF SOUTHOLD
APPLICATION IS HEREBY MADE, pursuant to th~~Jr~w 5oa~'0~
visions of Section 405.00 of the Penal Law of the State of New York,
for a permit to display fireworks as hereinafter specified:
The display is to be sponsored by w'?e-~F%~"e- (~ef~~i
_ with principal office at (~rc~w.:d Sfi~, u~
New York, and will be held on ~w ~ 7u~~
da month
1g (~~ at .3C'~ P.M. RAIN DATE: ~~ ~.c~ 7 ~~~
°-~- hour
The following persons are to be in charge of the
actual shooting of the fireworks:
Name
P~r A7x6~a NSoN 3 6
Ln~~,K l~iw~l 33
V~eyrt,-~~dU K8~
Experience
~Yvt ,
$'yvs•
l7 yvs,
Physical Condition
~X~ r~~ou
GK L e /~p~'I-
/!=x«/~~~, t
Number and tyge of fireworks is as follows:
t
,Lh7~rr
CO,
The fireworks will be stored in a covered truck
prior to the shooting on the grounds.
Attached hereto and made a part hereof is a diagram
of the grounds on which the display is to be held. Also attached is
the certificate or policy of insurance coverage.
Respectfully submitted,
(~r;raT %ve I/pnf`
name of organization /-
Dated: \ LNG ~ ~, ~ ~ ~~'
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