The URL can be used to link to this page

Home My WebLink AboutEpoch Films/Mark Von Holstein � oF so�ryol ELIZABETH A.NEVILLE,RMC,CMC O Town Hall, 53095 Main Road TOWN CLERK l l P.O. Box 1179 REGISTRAR,OF VITAL STATISTICS Southold, New York 11971 MARRIAGE OFFICER • �O� Fax(631) 765-6145 RECORDS MANAGEMENT OFFICER Ol� Telephone (631) 765-1800 FREEDOM OF INFORMATION OFFICER COU01� southoldtown.northfork.net OFFICE OF THE TOWN CLERK TOWN OF SOUTHOLD FILMING/STILL PHOTOGRAPHY PERMIT Issued to: Epoch Films/Mark von Holstein Date(s), Time(s) and Location October 11 2009 2-3 hours Rocky Point Beach Permit No. 024 Issue Date: 10/9/09 Elizabeth A. Neville Southold Town Clerk (Town Seal) } T 7� 4 OBRO 000 1 x1890 7112 October 16, 2009 Epoch Films ATT: Accounting 435 Hudson Street, #3 New York, NY 10014 Dear Sir/Madam: Enclosed find $250.00 clean-up deposit for the T-Mobile commercial that took place on October 11, 2009. There is also a receipt for the filming application and permit for your records. Sincerely, Lynda M Rudder Deputy Town Clerk enc Page 1 of 1 Y 7 s Rudder, Lynda From: Flatley, Martin Sent: Friday, October 16, 2009 10:59 AM To: Rudder, Lynda Subject: RE: filming permit Hi Lynda Checked the beach and parking lot at Rocky Point, East Marion this morning and both look clean after the shoot, recommend returning their deposit From: Rudder, Lynda Sent: Thursday, October 15, 2009 11:10 AM To: Flatley, Martin Subject: RE: filming permit whenever, thanks, From: Flatley, Martin Sent: Thursday, October 15, 2009 11:09 AM To: Rudder, Lynda Subject: RE: filming permit Can I get back to you tomorrow on that after I've had a chance to check? From: Rudder, Lynda Sent: Thursday, October 15, 2009 10:46 AM To: Flatley, Martin Subject: filming permit Epoch Films have completed filming at Rocky Point Road, can I release the clean up deposit Lynda M Rudder Lynda M Rudder Deputy Southold Town Clerk Principal Account Clerk 53095 Main Road PO Box 1179 Southold, NY 11971 (631)765-1800 ext 265 10/16/2009 FICC® USAirbill Track ng 8,703 1662 0552 - t ti Express Number 1 From 4 Express Package Service •Towealawda. Peckagasupto150tbs. Date FedEx Priority Overnight FedEx Standard Overnight FedEx Fist Overnight Nen huaneae moming.•Fridey ❑ Nenbwiness enemas..' ❑Eadiennen husiwsamaming shiPro't 1 be d.knred an Monday Saturday Delivery NOT available. dalivarytu as.laxations.' mr.as SATURDAY Delivery u sekctetl. Saturday Delivery NOT available. Senders / ❑shin ❑ FedEx Express Saver Seed2Deu deThird buenew day.•Name phone ill be dereurs .,day Saturday DeliveryNOTavallab le. uNenwRDAY Delivery is selected. Company L, i 4b Express Freight Service ••Tenestleeefiew Packagasover IMlbs. FedEx 1 Day Freight ElNanbusin—ry. Friday shipments will Dalrvery'sao relay unless SATURDAY FedFxlDayReightBadtlng Na Address Depl./fioodsuitadfoon FedE:Way Fre�ht 1:1 Secondbusinessdey. ThursdeyahpmentswillbedeAvred ❑ FedEx May Freight k! on Manley unless SATURDAY Delivery is selected. Thi dbusiness ey. Saturday Delivery NOT available. City d State ! ZIP l�t a' } Y 5 Vackaging •oeal.eaa.IwlllxtEm y dEx ❑ FedEx Pak* E]FedEx Box ❑FedEx Tube E]Other m 2 Your Internal Billing Reference Y nvelope* Includes FedEx Small Pak FedEx X Large Pak and FedEx Sturdy Pak n 3 To 6f Special Handling and Delivery Signature Options Nam ient s � 1,{ ,'}± ., Phone a /,t t E] SATURDAY Delivery o x fig NOTewBeNslor rad&Standard Overnight FedEx First Ovmlght FedEx Express Saver,or FedEx 3Day Freight „` , '- HOLDWeekday HOLDSaturda Indirect Si nature PdmFedExbcatinladdress PdmFadblocebon revs below. QQ a Company ; _?d y �' ❑ 6elmv.Normllohlek. ❑Asai6N DNpforrxdFx Pdoriry0vnegM ❑NoPackSig Bath�ee ReAunred Direct Signature ❑Rtoowuavakhis recsp.rRs �n FedEx Rist Overnight and FedExZDayto sawbwadwu. obtain. ra nature for delivery. A .. � .. w ._ Aa A ry m�eys�gnfard f mryHrweppfaa. ed�ddre�rom91'pn for deh%h Fwn ,Y y x i r^ ;. , "ential�deliveries only Fiateppdsa o },- °I y d Does this shipment contain dangerous goods? o E 3' '! Address 't "#�i` One box must be checked. w We cannot deliver to P.O.boxes or P.O.ZIP codas. Dep4Acor/S.iWR om I❑ ❑YBS ❑ YBS ❑ D ICs x W NO As Der poached Shippefs Declension Dry cwa SNDDefa Declaration. notrequred. Dryice,9,UNIM5 kg AddressB.Dangerous gouda lincludinp dry ice)cannot be shipped in Fedi packaging ❑ Cargo Aircraft Only pa Express Drop Prim FedEx location address here f e HOLD option is selected. or aced'. FedEx fi 7 Payment Bill to City ✓ �, 5 M' i/) Stats ZIP I Obtain Sender ERlor FedExAca.Noor Credit Card No.below. AI;cc,Nu. E]Axa Na.seoban ❑_Recipient Third Party ❑ Credit Card ❑ Cash/Check Total Packages Total Weight Total Declared Valuet OreadcardAuth, 10ur liability is imbed tuSlOD unless you declare a highervalu•.Seethe current FedEx Service cuidefordereile. 554 8703 1662 0552 ` Rev.Dna 1/08•Pert#759Y91•m1994-4008 FedEx-PRINTED IN U.S.A.SRY 1 l l Terms And Conditions .' , Definitions On this Airbill,"we,""our,""us,"and"FedEx" We won't be liable: Filing A Claim YOU MUST MAKE ALL CLAIMS IN referto Federal Express Corporation,its employees,and agents. —for your acts or omissions,including but not limited to WRITING and notify us of your claim within stricttime limits "You"and"your"referto the sender,its employees,and agents. improper or insufficient packing,securing,marking,or set out in the current FedEx Service Guide. Agreement To Terms By giving us your package to deliver, addressing,or those of the recipient or anyone else with You may call our Customer Service department at you agree to all the terms on this Airbill and in the current an interest in the package. 1.800.GoFedEx 1.800.463.3339 to report a claim;however, FedEx Service Guide,which is available upon request.You — if you or the recipient violates any of the terms of you must still file a timely written claim.We aren't obligated also agree to those terms on behalf of any third party with an our Agreement. to act on any claim until you have paid all transportation interest in the package.If there is a conflict between the charges,and you may not deductthe amount of your claim current FedEx Service Guide and this Airbill,the current FedEx —for loss of or damage to shipments of prohibited items. from those charges. Service Guide will control.No one is authorized to change —for loss,damage,or delay caused by events we cannot If the recipient accepts your package without noting any the terms of our Agreement. control,including but not limited to acts of God,perils of damage on the delivery record,we will assume the package Responsibility For Packaging And Completing Airbill the air,weather conditions,acts of public enemies,war, was delivered in good condition.For us to process your claim, You are responsible for adequately packaging our goods and strikes,civil commotions,or acts of public authorities you must make the original shipping cartons and packing p q y p g g Y g with actual or apparent authori n pp g properly filling out this Airbill.If you omit the number of tY� available for inspection. packages and/or weight per package,our billing will be based Declared Value Limits Right To Inspect We may,at our option,open and inspect on our best estimate of the number of packages we received .The highest declared value allowed for a FedEx Envelope or your packages before or after you give them to us to deliver. and/or an estimated"default"weight per package as FedEx Pak shipment is$500. Right Of Rejection We reserve the ri htto reject a determined by us. 9 I 9 1 Responsibility For Payment Even if you give us different .For other shipments,the highest declared value allowed is shipment when such shipment would be likely to cause payment instructions,you will always be primarily responsible for $50,000 unless your package contains items of extraordinary delay or damage to other shipments,equipment,or all delivery costs,as well as any cost we incur in either returning value,in which case the highest declared value allowed personnel;or if the shipment is prohibited by law;or if the your package to you or warehousing it pending disposition. is$500. shipment would violate any terms of our Airbill or the current •Items of extraordinary value include shipments containing FedEx Service Guide. Limitations On Our Liability And Liabilities such items as artwork,jewelry,furs,precious metals,nego- C.O.D.Services C.O.D.SERVICE IS NOT AVAILABLE WITH Not Assumed tiable instruments,and other items listed in the current FedEx THIS AIRBILL.If C.O.D.Service is required,please use a FedEx •Our liability in connection with this shipment is limited to the Service Guide. C.O.D.Airbill. lesser of your actual damages or$100,unless you declare a .You may send more than one package on this Airbill and fill Air Transportation Tax Included A federal excise higher value,pay an additional charge,and document your in the total declared value for all packages,notto exceed tax when required by the Internal Revenue Code on the air actual loss in a timely manner.You may pay an additional charge for each additional$100 of declared value.The the$100,$500,or$50,000 per package limit described above. transportation portion of this service,if any,is paid by us. can have a total declared value of u declared value does not constitute,nor do we provide,cargo (Example: 5 packages p p g p Money-Back Guarantee In the event of untimely delivery, liability insurance. to$250,000.)In that case,our liability is limited to the actual FedEx will,at your request and with some limitations,refund value of the package(s)lost or damaged,but may not exceed or credit all transportation charges.See the current FedEx •In any event,we will not be liable for any damage,whether the maximum allowable declared value(s)orthe total declared Service Guide for more information. direct,incidental,special,or consequential,in excess of the value,whichever is less.You are responsible for proving the declared value of a shipment,whether or not FedEx had actual loss or damage. knowledge that such damages might be incurred,including but not limited to loss of income or profits. Pan#158280/81•R-2/08 t s VOLIC DEIDAQTMENT TOWN Of (SOUTHOLD CARLISLE E. COCHRAN,JR. Telephone Emergency Dial 911 Chief of Police MEMORANDUM TO: Lynda M. Rudder,Deputy Town Clerk FROM: Chief Carlisle E. Cochran, Jr. tL� DATE: October 6, 2009 RE: Filming Permit-Mark von Holstein-Epoch Films As per Section 44A.3 of the Southold Town Code, it is the recommendation of the Chief of Police that application dated October 1, 2009, Epoch Films/Mark von Holstein,be APPROVED. There will be no need for police involvement in this filming, therefore, no fee will be required. 41405 Route 25 • P.O. Box 911 • Peconic, N.Y. 11958 Administrative (631) 765-2600/2601 9 Fax (631) 765-2715 o*rjfr SO(/r�ol ELIZABETH A.NEVILLE,RMC,CMC O Town Hall, 53095 Main Road TOWN CLERK P.O. Box 1179 REGISTRAR,OF VITAL STATISTICS Southold, New York 11971 MARRIAGE OFFICER COQ Fax(631) 765-6145 RECORDS MANAGEMENT OFFICER Oly Telephone (631) 765-1800 FREEDOM OF INFORMATION OFFICER Own southoldtown.northfork.net OFFICE OF THE TOWN CLERK TOWN OF SOUTHOLD To: Southold Town Attorney's Office From: Lynda M Bohn Dated: October 2, 2009 Re: Filming Permit In accordance with the Southold Town Code, Chapter, Section 3, Subsection D, the Certificate of Insurance and Indemnification Agreement for a Filming Permit Application for Mark von Holstein of Epoch Films for a T Mobile commercial are attached hereto. Please review and advise whether these documents mee h your approval. Thank you. Approved as submitted Disapprove for the following reasons: Signature V14T� O� T i��fh'�v1� SIS 10�t1'Oq. l�eu� �tnsu,ra�ee C�.r-E-i��ea c h�+b bQen V'egve5fecf 00 CT - 2 2009 a, ` APPLICATION FOR FILMING/STILL PHOTOGRAPHY r PERMIT NO: Please Print or Type APPLICATION DATE:: October I, 2009 NAME OF APPLICANT: Mark von Holstein RECEIVED MAILING ADDRESS: 435 Hudson Street, 3rd floor, New York NY 10014 PHONE: BUSINESS: 917 446 9969 cell HOME: 914 864 2434 OCT — 2 2009 NAME OF COMPANY: E,,^, h Films MAILING ADDRESS: 435 Hudson Street, 3rd floor, New York NY 10014 Southold Town Clerk PHONE: 212 226 0661 FAX 212 226 4893 DESCRIBE TYPE OF ACTIVITY(e.g. Motion Picture, Commercial, Television. Catalog, Magazine, etc.): Filming a commercial for T-Mobile. DATE(S) AND TIME(S) OF PROPOSED FILMING / PHOTOGRAPHY: Sunday, October 11, 2009 2-3 hours TBD based on available light. PROPOSED LOCATION(S) OF FILMING/ PHOTOGRAPHY: (attach additional sheet, if necessary) Rocky Point Beach NAME OF PERSON IN CHARGE AT SITE: Mark von Holstein, Locations manager NUMBER OF PERSONS AT LOCATION (cast &crew included): 24 NUMBER AND TYPE OF VECHILES AT LOCATION: 8 vehicles: 3 cars. 3 passenger vans. 2 cube trucks TYPE OF SPECIAL EQUIPMENT: 35mm camera+ grip&electric. ANY SPECIAL REQUIREMENTS: None Signature Return to: Southold Town Clerk Southold Town Hall 53095 Main Road P.O. Box 1 179 Southold, NY 11971 WWW.EPOCHFILMS.COM INDEMNIFICATION RECEIVED OCT - 2 2009 October I, 2009 Southold Town Clerk Epoch Films assumes all liability for, and will indemnify and hold the Town of Southold harmless, and free of, any and all damages that occur to persons or property by reason of company's filming in the Town of Southold. AGREED: Mark von Holstein, Locations manager dcily6 t,Q I ) 2v�� Date INFO@EPOCHFILMS.COM WWW.EPOCHFILMS.COM RECEIVED OCT — 2 2009 Southold Town Clerk J -9969 �ti.l`11• S w 1 ��'R �'� � L� INFO@EPOCHFILMS.COM ACOR CERTIFICATE OF LIABILITY INSURANCE DA7e1o/1`009Y' PRO ICER T THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER OTHER THAN THOSE DeWitt'Stern Group, Inc. PROVIDED IN THE POLICY. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 420 Lexington Avenue ALTER THE COVERAGE AFFORDED BY THE POLICIES HEREIN. New York, NY 10170 COMPANIES AFFORDING COVERAGE Stacie O'Beirne Tel: 212-297-1427 COMPANY A Fireman's Fund Insurance Company INSURED PUBLICIS COMPANY Epoch Films B Chubb 435 Hudson St., 3r° Floor COMPANY New York, NY 10014 C COVERAGES This certificate su rcedes and replace any reviousl issued•certificate for the Dli eriod noted below. THIS IS TO CERTIFY THAT POLICIES OF INSURANCE DESCRIBED HEREIN HAVE BEEN ISSUED TO THE INSURED NAMED HEREIN FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THE CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,CONDITIONS AND EXCLUSIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. CO TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LIMITS LTR DATE(MMIDD/YY) DATE(MMIDD/YY) GENERAL LIABILITY GENERALAGGREGATE $2,000,000 A ®COMMERICAL GENERAL LIABILITY XXC 80442401 10/1/08 10/1/09 PRODUCTS-COMP/OP AGG $1,000,000 ❑CLAIMS MADE® OCCURRENCE PERSONAL&ADV INJURY $1,000,000 EACH OCCURRENCE $1,000,000 ❑OWNER'S&CONTRACTOR'S PROT FIRE DAMAGE(Any one fire) $1,000,000 ❑ MED PAY(Any one person) $ 10,000 AUTOMOBILE LIABILITY A ANY AUTO XXC 80442401 10/1/08 10/1/09 COMBINED SINGLE LIMIT $1,000,000 ❑ALL OWNED AUTOS BODILY INJURY $ (Per person) ❑SCHEDULED AUTOS MPT07108144 10/1/08 10/19 BODILY INJURY $ ® HIRED AUTOS (Per accident) ® NON-OWNED AUTOS Physical Damage $Inc).in Misc. Equipment Limit 191 GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ❑ANY AUTO OTHER THAN AUTO ONLY: EACH ACCIDENT $ AGGREGATE $ EXCESS LIABILITY EACH OCCURRENCE $19,000,000 B ®UMBRELLA FORM 7953-49-54 10/1/08 10/1/09 AGGREGATE $19,000,000 ❑OTHER THAN UMBRELLA FORM $ WORKERS COMPENSATION WC STATUTORY OTHER AND EMPLOYERS'LIABILITY $ $ THE PROPRIETOR/ $ $ PARTNERS/EXECUTIVE OFFICERS ARE $ $ OTHER DEDUCTIBLES A Errors&Omissions MSF07004748 10/1/08 10/1/09 Limit$1,000,000 Ded.$25,000 A Miscellaneous Equipment MPT07108144 10/1/08 10/1/09 Limit$2,000,000 Ded.$ 2,500 Props/Sets/Wardrobe Limit$1,000,000 Ded.$ 1,500 Third Party Damage Limit$1,000,000 Ded.$ 1,500 DESCRIPTION OF OPERATXW--AOCAMNSIVEH/CLESBPEC/AL ITEMS(UM/TS MAY BE SUB.ECT TO DEDUCTIBLE OR RETENTIONS) Certficate Holder is included as an Additional Insured and Loss Payee as their interest may appear as respect production work done on behalf of Agency: Publicis; Client: T-Mobile; Job No: 366-4024TCB9281; Commercial Title:We Asked America #1 and 2. With respect to others, coverage is worldwide, in transit and All Risk. With respect to Automobile Rentals, Non-Owned &Hired Auto Physical Damage, limits are included in Miscellaneous Equipment. Deductible: 10%of loss; $2,500 Min./$7,500 Max (per occurrence) PUBLICIS. CERTIMCATS HOLDER, ., CANCELLATION:.. SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE TOWN OF SOUTHOLD RECEIVED THEREOF,THE INSURER AFFORDING COVERAGE WILL ENDEAVOR TO MAIL a DAYS WRITTEN NOTICE TO 53095MAINROAD THE CERTIFICATE HOLDER NAMED HEREIN,BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR PO BOA 1 179 LIABILITY OF ANY KIND UPON THE INSURER AFFORDING COVERAGE,ITS AGENTS OR REPRESENTATIVES. SOUTHOLD, NY 11971OC _ 2 200th DeWIHStern Group Inc. r1k BY: MM11(WIRY, VALID.AS OF $20M TOWN CLERK'S CHECKLIST FOR FILMING PERMIT NOTE: All payments must be cash or certified check Applicant: M Ar k Voy% I STe i h AINA Date Received: 10 - A-09 ✓ Completed application 0\\t�,' $100 nonrefundable application fee `/ Certificate of insurance that evidences a public liability insurance policy covering the town as an additional insured in the amount of$1,000,000 (one million dollars) per occurrence for the duration of the filming or still photography. ✓- Indemnification agreement stating the applicant agrees to assume all liability for and will indemnify and hold the town harmless of and free from any and all damages that occur to persons or property by reason of said filming or still photography. Forward completed application to Chief of Police for approval or disapproval and determination if Traffic Control Fee is required Approved Disapproved No Fee Required / Fee in the amount of$ required ✓ Forward certificate of insurance and indemnification agreement to Town Attorney for proval Approved Disapproved COLLECT FEES AS FOLLOWS: Permit Fees (Prior to issuance of permit): Film Fee - $100 per day of each day covered by the permit Cleanup deposit: Separate certified check for $250 for each day covered by the permit. Traffic control fee - $1000 for each day covered by the permit if required by the Chief of Police. NOTE: Additional funds may be required by Police if it is determined that $1000 per day fee will be expended prior to the termination of the permit period. • w Beach Parking fee - $10 per vehicle, per day between May 1 and September 30. ISSUED PERMIT Countersign application Issue permit with name of applicant, locations(s), date(s), and time(s) NOTIFICATION of ISSUED PERMIT Chief of Police Chief Building Inspector Fire Marshal Code Enforcement Officer Superintendent of Highways Superintendent of Parks and Recreation REQUEST FOR EXTENSION OF PERMIT Forward extension permit request to Chief of Police If granted, collect additional $100 per day filming fee Amend permit to indicate granted extension period COMPLETION OF PERMIT PERIOD Chief of Police to provide applicant with statement of cost for providing Traffic Control and police coverage. (Refund overpayment or collect for additional costs within 30 days of termination of permit) Superintendent of Highways inspections locations listed on permit and determine if cleanup efforts by town personnel is required. *If cleanup is required, Superintendent will provide Town Clerk with a statement of actual costs. (Refund overpayment or collect for additional costs within 30 days of termination of permit) *If not cleanup is required, Superintendent of Highways will notify Town Clerk and Town Clerk will remit the $250 certified check to applicant. so ALIZABETH A.NEVILLE,RMC,CMC �� l0 Town Hall, 53095 Main Road TOWN CLERK J l P.O. Box 1179 REGISTRAR OF VITAL STATISTICS H Southold, New York 11971 MARRIAGE OFFICER 'G�► • �O� Fax(631) 765-6145 RECORDS MANAGEMENT OFFICERTele hone(631) 765-1800 FREEDOM OF INFORMATION OFFICER IyIrou Y,� southoldtown.northfork.net OFFICE OF THE TOWN CLERK TOWN OF SOUTHOLD To: Southold Town Attorney's Office From: Lynda M Bohn Dated: October 2, 2009 Re: Filming Permit In accordance with the Southold Town Code, Chapter 44A, Section 3, Subsection D, the Certificate of Insurance and Indemnification Agreement for a Filming Permit Application for Mark von Holstein of Epoch Films for a T Mobile commercial are attached hereto. Please review and advise whether these documents meet with your approval. Thank you. Approved as submitted Disapprove for the following reasons: Signature O�\\pF SO!/ryol ALIZABETH A.NEVILLE,RMC,CMC h O Ton Hall, 53095 Main Road TOWN CLERK J�[ J P.O. Box 1179 REGISTRAR OF VITAL STATISTICS G Q Southold New York 11971 MARRIAGE OFFICER Fax(631) 765-6145 RECORDS AGEMENT OFFICER Telephone (631) 765-1800 FREEDOM OF INFORMATION OFFICER OI�COU ,� southo dto n.northfork.net OFFICE OF THE TOWN CLERK TOWN OF SOUTHOLD To: Chief Cochran, Southold Town Police From: Lynda M Rudder, Deputy Town Clerk Dated: October 2, 2009 Re: Filming Permit Transmitted herewith is the application of Mark von Holstein of Epoch Films for a T Mobile commercial filming permit. In accordance with Section 139.0 of the Town Code please review the application and advice of approval or disapproval of the application and whether a traffic control fee is required and the amount needed. APPLICATION FOR FILMING/STILL PHOTOGRAPHY PERMIT NO: Please Print or Type APPLICATION DATE:: October I, 2009 NAME OF APPLICANT: Mark von Holstein RECEIVED MAILING ADDRESS: 435 Hudson Street, 3rd floor, New York NY 10014 PHONE: BUSINESS: 917 446 9969 cell HOME: 914 864 2434 OCT — 2 2009 NAME OF COMPANY: Epoch Films MAILING ADDRESS: 435 Hudson Street, 3rd floor, New York NY 10014 Southold Town Clerk PHONE: 212 226 0661 FAX: 212 226 4893 DESCRIBE TYPE OF ACTIVITY (e.g. Motion Picture, Commercial, Television. Catalog, Magazine, etc.): Filming a commercial for T•Mobile. DATE(S) AND TIME(S) OF PROPOSED FILMING / PHOTOGRAPHY: Sunday, October 11, 2009 2-3 hours TBD based on available light. PROPOSED LOCATION(S) OF FILMING/ PHOTOGRAPHY: (attach additional sheet, if necessary) Rocky Point Beach NAME OF PERSON IN CHARGE AT SITE: Mark von Holstein, Locations manager NUMBER OF PERSONS AT LOCATION (cast& crew included): 24 NUMBER AND TYPE OF VECHILES AT LOCATION: 8 vehicles: 3 cars. 3 passenger vans. 2 cube trucks TYPE OF SPECIAL EQUIPMENT. 35mm camera + grip & electric. ANY SPECIAL REQUIREMENTS: None Signature Return to: Southold Town Clerk Southold Town Hall 53095 Main Road P.O. Box 1 179 Southold, NY 11971 WWW.EPOCH FILMS.COM INDEMNIFICATION RECEIVED 0G T - 2 2009 October I, 2009 Southold Town Clerk Epoch Films assumes all liability for, and will indemnify and hold the Town of Southold harmless, and free of, any and all damages that occur to persons or property by reason of company's filming in the Town of Southold. AGREED: Mark von Holstein, Locations manager 2009 Date INFO@EPOCHFILMS.COM 'WWW.EPOCHFILMS.COM RvCEIVED — 2 2009 Southo!d Town Clerk P � Ap, �q INFO@EPOCHFILMS.COM DATE(MM/DDNYYY) ACORD CERTIFICATE OF LIABILITY INSURANCE 10/1/2009 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND I CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER OTHER THAN THOSE DeWitt Stern Group, Inc. PROVIDED IN THE POLICY. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 420 Lexington Avenue ALTER THE COVERAGE AFFORDED BY THE POLICIES HEREIN. New York, NY 10170 COMPANIES AFFORDING COVERAGE Stacie O'Beirne Tel: 212-297-1427 COMPANY A Fireman's Fund Insurance Company INSURED PUBLICIS COMPANY Epoch Films B Chubb 435 Hudson St., 3rd Floor COMPANY New York, NY 10014 C COVERAGES This certificate su ercedes and replaces any previouslyissued certificate for the policy period noted below. THIS IS TO CERTIFY THAT POLICIES OF INSURANCE DESCRIBED HEREIN HAVE BEEN ISSUED TO THE INSURED NAMED HEREIN FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THE CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,CONDITIONS AND EXCLUSIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. CO IO TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LIMBS LTR DATE(MUMD/YY) DATE(MM/DD/YY) GENERAL LIABILITY GENERALAGGREGATE $2,000,000 A ®COMMERICAL GENERAL LIABILITY XXC 80442401 10/1/08 10/1/09 PRODUCTS-COMP/OP AGG $1,000,000 ❑CLAIMS MADE® OCCURRENCE PERSONAL&ADV INJURY $1,000,000 EACH OCCURRENCE $1,000,000 ❑OWNER'S&CONTRACTOR'S PROT FIRE DAMAGE(Any one fire) $1,000,000 ❑ MED PAY(Any one person) $ 10,000 AUTOMOBILE LIABILITY AANY AUTO XXC 80442401 10/1/08 10/1/09 COMBINED SINGLE LIMIT $1,000,000 ❑ ❑ALL OWNED AUTOS BODILY INJURY $ (Per person) ❑SCHEDULED AUTOS MPT07108144 10/1/08 10/1/09 BODILY INJURY $ ® HIRED AUTOS (Per accident) ® NON-OWNED AUTOS Physical Damage $Incl.in Misc. 10 Equipment Limit GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ❑ANY AUTO OTHER THAN AUTO ONLY: ❑ EACH ACCIDENT $ AGGREGATE $ EXCESS LIABILITY EACH OCCURRENCE $19,000,000 B ®UMBRELLA FORM 7953-49-54 10/1/08 10/1/09 AGGREGATE $19,000,000 ❑OTHER THAN UMBRELLA FORM $ WORKERS COMPENSATIONWC STOTHER AND EMPLOYERS'LIABILITY 0 $ $ THE PROPRIETOR/ $ $ PARTNERS/EXECUTIVE OFFICERS ARE $ $ OTHER DEDUCTIBLES A Errors&Omissions MSF07004748 10/1/08 10/1/09 Limit$1,000,000 Ded.$25,000 A Miscellaneous Equipment MPT07108144 10/1/08 10/1/09 Limit$2,000,000 Ded.$ 2,500 Props/Sets/Wardrobe Limit$1,000,000 Ded.$ 1,500 Third Party Damage Limit$1,000,000 Ded.$ 1,500 DESCRIP77ON OF OPERATIONS4.00A77ONSIVEHICLEWPECIAL ITEMS(UNITS MAY BE SUBJECT TO DEDUCTIBLE OR RETENTIONS) Certficate Holder is included as an Additional Insured and Loss Payee as their interest may appear as respect production work done on behalf of Agency: Publicis; Client: T-Mobile; Job No: 366-4024TCB9281; Commercial Title: We Asked America #1 and 2. With respect to others, coverage is worldwide, in transit and All Risk. With respect to Automobile Rentals, Non-Owned &Hired Auto Physical Damage, limits are included in Miscellaneous Equipment. Deductible: 10% of loss; $2,500 Min./$7,500 Max (per occurrence) PUBLICIS. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE TOWN OF SOUTHOLD RECEIVED THEREOF,THE INSURER AFFORDING COVERAGE WILL ENDEAVOR TO MAIL 22 DAYS WRITTEN NDTICE TO 53095 MAIN ROAD THE CERTIFICATE HOLDER NAMED HEREIN,BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR PO BOX 1179 LIABILITY OF ANY KIND UPON THE INSURER AFFORDING COVERAGE,ITS AGENTS OR REPRESENTATIVES. SOUTHOLD, NY 11971 / 10�� DeWIttStern OCT I L Group Inc. { ,( By: MM1 "e _VALID AS OF W2WO9 10/02/2009 11; 23 FAX 1a002/002 DATE(MM/DDlY Y Y Y j A��RD CERTIFICATE OF LIABILITY INSURANCE 10/2/2009 PgODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER OTHER THAN THOSE DeWitt Stern Group, Inc. PROVIDED IN THE POLICY, THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 420 Lexington Avenue ALTER THE COVERAGE AFFORDED BY THE POLICIES HEREIN. New York, NY 10170 COMPANIES AFFORDING COVERAGE Stacie O'Be me Tel: 212-297-1427 COMPANY A One Beacon America Insurance Co, INSURED COMPANY Epoch Film�; B Chubb 435 Hudson St,, 3r0 Floor COMPANY New York, NY 10014 C Hiscox COVERAGES This certificate su ercedes and replaces any previouslyissued certificate for the policy period noted below. THIS IS TO CERTIFY THAT POLICIES OF INSURANCE DESCRIBED HEREIN HAVE BEEN ISSUED TO THE INSURED NANIED HEREIN FOR THE POLICY PERIOD INDICATED NOTA11THSTANDING ANY P,EOUIREMENT.TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH.gESPECT TO 11,41HICH THE CERTIFICATE MAY BE ISSUED OR MAY PERTAIN.-.Hc INSURANCE AFFORDED BY THE POLICIES DESCRISED HEREIN IS SUBJECT TO ALL THE TERMS.CONDITIONS AND EXCLUSIONS OF SUCH POLICIES LIMITS SHCIA'N M9 Y HAVE BEEN REDUCED BY PAID Cl-AINAS CO TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LIMITS LTR DATE(MM/DD/YY) DATE(MM/DD/YY) GENERAL LIABILITY GENERAL.AGGREGATE 51:000,000 A ® COMMERICAL GENERAL LIABILITY CP01327.00 10/11,09 10/1/10 PgODUCTS-CONIP/OP AGO 51,000.000 PERSONAL&ADV INJURY $1,000,000 ElCLARv1S MA ADE® OCCURRENCE EACH OCCURRENCE $1,000000 ❑ 01,N%=R'S&CONTRACTORS ERCT FIRE DAMAGE(Any one tae! S1,000.000 ❑ I:IED P.AY ,Any one personi S :1.000 AUTOMOBILE LIABILITY A ❑ AN"AL 710 CP01327-00 10/1/09 10/1/10 COMBINED SINGLE LIMIT $1,000,000 El ALL OBODILY INJURYOWNED AUTOS (Per pe!son;� $ ❑ SCHEDULED AUTOS D100368.00 10111,09 1011110 BODILY INJURY S ® HIRED AUTOS ;Per a:ciden!) ® NCN•O'JVNEDALITOS Physical Damage $Incl in Misr. Equipment I-Im11 GARAGI;LIABILITY AUTO CN!_Y-EA ACCIDENT $ ❑ AN1'AUTO OTHER THAN AUTO ONLY. ❑ i EACH ACCIDENIT $ AGGREGATE $ EXCESS LIABILITY EACH OCCURRENCE $19,000:000 B ® LRdRRELi-A FORM 7953.49-54 1CU1/09 10!1/10 1 AGGREGATE $19,000.000 I ❑ OTHER THAN UMBRELLA FORM, I $ WORKERS COMPENSATION Ylc STATtrORY ❑ Omen AND EMPLOYERS'LIABILITY 5 $ THE PROPRIETOW �- $ PARTNERS'EXECUTIVE OFFICERS ARE 5 $ OTHER UMTS DEDUCTIBLES C Errors 8:Omissions USUUA2620608.9 10/1/09 10./1i10 ' $1,000,000/$3,000,000 $25.000 A MiscelleneousEquipmeni D100368-00 t0iii09 10/1/10 $2.500,000 $ 3,500 Props/Sets/Wardrobe 1 $1,000,000 $ 2.000 Third Party Property Damage 51,000,000 $ 2000, Negative Film&Videotape &5,000,000 NIL Faulty Stock.Camera&Processing ' $5,000.000 10%of loss Extra Expense $2,000,000 $ 3,500 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/SPECIAL ITEMS(LIMITS MAYBE SUBJECT TO DEDUCTIBLE OR RETENRONS) Certficate Holder is included as an Additional Insured and Loss Payee as their interest may appear as respect production work done on behalf of Agency: Publicis; Client: T-Mobile; Job No; 366-4024TCB9281; Commercial Title: We Asked America #1 and 2. With respect to ethers, coverage is worldwide, in transit and All Risk. With respect to Automobile Rentals, Non-Owned & Hired Auto Physical Damage, limits are included in Miscellaneous Equipment. Deductible: 10% of loss; $2,500 Min./57,500 Max (per occurrence) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABL!Vr I]I"SCnI B EO POIAUFS BE ,AN(,,FI.i.FD BEFORE TIME IXVIfi ATK1N DATF TOWN OF SOUTHOLD rHEREOF THEINSIIRERAFFORL)INGCOVERAC1,E'RILL ENDEAVOR TO I.IA'L]o riAYti yyRl71 NOM^F:TO 53095 MAIN ROAD THE C ERTIFIGATC HOLDER NAFAEU HEREIN BLIT FAILURE TO DG SC`:HALL IM;20.SF NO n31IGATION C1R PO BOX 1179 LIABILITY OF ANY KIND;lPONTHE.INSURER AFF'OHOING GOVERAGE.R1,AGENTS OR RC:r Rf`.tiEr1T l.T!VF S. SOUTHOLD, NY 11971 DeWitt Stwn Group Inc. 1 By MM1(9/99) VALID AS OF 10/2/2009 10/02/2009 11;22 FAX 0 001/002 • I n A ' EPOCH FILMS FAX COVER PAGE T0: FAX NUMBER: 3l Co . C9l6/5 FROM: Seo ci DATE: NUMBER OF PAGES (including cover): RE: If you have problems receivi g this fax, please call 212 226 0661 Vk The information contained in this facsimile is confidential information intended only for use of the individual or entity named above, If the reader of this message is not the intended recipient,or the employee or agent responsible to deliver it to the intended recipient,you are hereby notified that any dissemination,distribution or copying of this communication is strictly prohibited. If you receive this communication in error, please immediately notify us by telephone,and return the original message to us at the below address via the U.S. Postal Service.Thank you. 435 fiudson Street New York N Y 10014 Telt 212 226 0661 Fax; 212 226 4893 9290 Civic Center Drive Beverly hills CA 90210 Tel:310 275 9333 Fax: 310 275 7696 J I i Postal CERTIFIED MAIL,. RECEIPT r1J (Domestic Mail Only; r=1 F. I ° SKIP ru CO Ou Postage $Certified Fee p Return Receipt Fee p (Endorsement Required)O Restricted Delivery Fee O (Endorsement Required) � Total Postage&Fees $ O Sen ToEr o.; Street}'Apt.N {� N or PO Box No. _�. .... ....... ......... it Stre _.._ ..... . .. i City State,ZIP+4. fV C for Instructions LPS Form :00 COMPLETEY, )N DELIVERY ■ Complete items 1,2,and 3.Also item 4 if Restricted Delivery Is desired. 0 Agent ■ Print your name and address on the reverse ❑Addressee so that we can return the card to you. ltir@6) C. Date of Delivery ■ Attach this card to the back of the mailplece, or on the front if space permits. D.-Ie d*"addmw from item 1? OYes i. 1. Article Addressed to: N YE%enter delivery address below. 0 No �.�p�.h F; lw►.s �. Atl� �ccour�4�ltr, l��•prt- I �S X135 �-\vdsor, fit-, �3 b a TAO 1AeU.3 40,rl( Ivy 100(�� Mtwftd MNA o Bpess Mail -G Ind' 17 Return Receipt for M 0Irmaw 11Aaq,-Z ebb. 'A 4. R Ihmsof4wty+l113tFee) Yes 2. Article Number 7009 08x0 000.1. 7820 7412 (Transfer from,servIae low PS Form 3811,Febriialyt2E �/' to25sp o2-M-isao I i