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HomeMy WebLinkAboutW Magazine/Fairchild Publishing + o�$uFF01,�o 0 ELIZABETH A.NEVILLETown Hall,53095 Main Road TOWN CLERK G Z P.O.Box 1179 REGISTRAR OF VITAL STATISTICSO Southold,New York 11971 MARRIAGE OFFICER y • 0`� Fax(631) 765-6145 RECORDS MANAGEMENT OFFICER ��l �►� Telephone(631) 765-1800 FREEDOM OF INFORMATION OFFICER southoldtown.northfork.net OFFICE OF THE TOWN CLERK TOWN OF SOUTHOLD August 9, 2004 CERTIFIED MAIL RETURN RECEIPT REQUESTED Nadia Vellam 153 E 87th St,Apt 3A New York,NY 10129 Dear Ms. Vellam: Returned herewith are your two (2)certified checks No. 387434967 and No. 387434968 in'the amount of$250.00 each that were being held for cleanup fees as required by the Southold Town Code, Chapter 44A. An inspection of the permit site was made and no cleanup was necessary. I hope everything went well with the filming. If I can be of any assistance in the future,please do not hesitate to contact me. SECTIONSENDER:-COMPLETE THIS SECTION COMPLETE THIS ■ Co plete items 1,2,and 3.Also complete A. Re i ed by(Please P'nt CI ilyj w -91 Deliver ite 4 if Restricted Delivery is desired. V/ ■ Pri t your name and address on the reverse C. Signet so that we can return the card to you. \, p A990. ■ Attach this card to the back of the mailpiece, X ❑Addressee or on the front if space permits. is d very address different from item 1? ❑Yes 1. Article Addressed to: If YES,enter delivery address below: ❑No 3. Service Type 8'�ertified Mail ❑ Express Mail ❑ Registered ❑Return Receipt for Merchandise ❑ Insured Mail ❑C.O.D. 4. Restricted Delivery?(Extra Fee) ❑Yes 2. Article Number(Copy from service label) 7000 vG o v OJ SAAZAE 102595-00-M-0952 PS Form 3811,July 1999 Domestic Return Receipt I It i{\r/'! t\ 111 <11 { rr EE jj;j` !�`\ \� �� '*� f l�T ✓ j �\�v ir+ �� \� \\ \'�. *�rri � ,�.�, r.,.v Imo,\. \ Jft ��, .,. s, 3 {t jt•//' j.r'j\t I tt{ i{�� if w �t ✓ : }.• {""� I f" `` \��`, " f , try' fill C111" MH 35 4 TIMS I T i" 3rf , " /%a/w,•reY' ,. i'fl7�r+'A��tI/S�'.kY3ylt� , s a ..F.A��`:rw„���'��'1'�►'�� -:.�R �y�;t 4'w�` 'r f.e"\^\� 1�•�.;f�.,�\t t\�: #� "NO1 011 �� 2—Iffill r Ulf- Wit I �I1��i.^!y f -• t'q'rf` "..1`i'"ia 1" #.( � }�� +A�y'ri +'�\�4''*.c.`t��"�'S,',{�� '\ �`` V01,tptro` !i#1 .r? �. 1f a \ ` ♦ �.rrlIJIMIMMOINI �.•!fli iI,{)�t7;r'�,y.�f�.•E'���!'��li�i I###��I.r'�tt '•i p�S:°';�a 1 _ ■ i i 1 Uornp►ete its • 7tern 4 if Restrlc{'2,and 3,�� • Print your name °slivery is des)omP►ete that we can rstum the � • Attach this ca °n the reverse A. Received by or on rd to the a card to you. �P/ease Pint c�,,J B. the front if Date of Delivery space back t.the rna"Piece, C• Signature 1• Article Add Permit..ceased to: X Is delivety ❑Agent If YES,enter dryf�nt from It ❑ ti rj/Gs �ioj X1.1X1.1 �Y address t T belo0 Yes w: ❑Nyes o 3 Service Type AftertiBed Mail 2 Article Nt,m 0 Insured seg'lstered O R Press Mail I'S Fonn •lu(Copy�m turn service label) 4. Restr c ❑C O.D Reoelpt for Merchandise G O ded ?�Delivery Fee) ---- 3811. ly 7sss ov ❑Yes Domestic Return Receipt s 102595-00_M-0952 Postal CERTIFIED MAIL RECEIPT 1• • No/'7s'JtJt'ce Coverage Provided) co C13 ni ru c c 'n u, TOGd,�J W PostagC3 Om rrt Certified FeOr 11' Return Receipt FePostmark111111 (Endorsement RequiredHere G O Restricted Delivery Fee O O (Endorsement Required) C I Total Postage&Fees �.•�r���. . —a � LR@cJ1p4wt'sse Print Clearly)(to be completed by mailed�/EL.GI�/------------------------p p o No.��. O C3© o7 s ---------P I -/ -u Y Y o�osuFFot�.� ELIZABETH A.NEVILLE �� Town Hall, 53095 Main Road ca TOWN CLERK C*3 Z P.O. Box 1179 REGISTRAR OF VITAL STATISTICS O Southold, New York 11971 MARRIAGE OFFICER y�• a��� Fax(631) 765-6145 RECORDS MANAGEMENT OFFICER Telephone (631) 765-1800 FREEDOM OF INFORMATION OFFICER southoldtown.northfork.net OFFICE OF THE TOWN CLERK TOWN OF SOUTHOLD RECEIVED To: Peter Harris, Superintendent of Highways AUG From: Linda J. Cooper, Deputy Town Clerk Dated: August 4, 2004 Southold town Clork Re: Film Permit No. 015 Cleanup Deposit In accordance with §44A-5 of the Southold Town Code,please advise if the $250.00 daily Cleanup deposit may be returned to the applicant; if not,please provide a statement setting forth the actual cost to the town of providing said cleanup servic . Cleanup was not required at the location(s) identified on the permit. The deposit may be returned. Cleanu was required. Actual cost statement is attached. Signature i6ate ELIZABETH A.NEVILLE ~� � Town Hall,53095 Main Road TOWN CLERK = P.O. Box 1179 REGISTRAR.OF VITAL STATISTICSO Southold, New York 11971 5 MARRIAGE OFFICER Pax(631) -6145 P RECORDS MANAGEMENT OFFICER ���• aO�� Telephone(631) 65-800 �it �► FREEDOM OF INFORMATION OFFICER southoldtown.northfork.net OFFICE OF THE TOWN CLERK TOWN OF SOUTHOLD FILMING/STILL PHOTOGRAPHY PERMIT Issued to: W MAGAZINE/FAIRCHILD PUBLISHING Location(s),Time(s) and Date(s) Location: 1167 Steps",Sound Road,Greenport,New York Time and Dates: 8:00 AM to 8:00 PM Wednesday,July 28,2004 and Thursday,July 29,2004 Permit No. 015 Issue Date: July 27,2004 Elizabeth A.Neville Southold Town Clerk (Town Seal) Town Of Southold P.O Box 1179 Southold, NY 11971 * * * RECEIPT * * * Date: 07/27/04 Receipt#: 387434966 Transaction(s): Subtotal 1 Application Fee- Non-Refund $100.00 8 Beach Permits $80.00 2 Daily Filming Permit $200.00 Check#: 387434966 Total Paid: $380.00 Name: Vellam, Nadia For W Magazine/fairchild Publishing 153 E 87th St#3a New York, NY 10128 Clerk ID: LINDAC Intemal ID:98780 27/07 '04 TUE 16:54 FAX 631 765 6145 SOUTHOLD TJ ` TX REPORT Al a TRANSMISSION OK TX/RX0741 CONNECTION CONNECTITI ON TEL /J CONNECTION ID TIME 27/07 16: USAGE T 01,09 / PGS. SENT 4 RESULT OK jeo' —• ELIZABETR A.NEVILEE r � TOWN CLERIC REGISTRAR OF VITAL STATLSTICS r 71 MARRIAG60FFICIrR RECORDS MANAGEMENT OITICER FREEDOM OF INFORMATION OFFICER OFFICE OF THE TOWN CLERK-TO" FAX TRANS NUTTAL To: Nadia Vellam From: Linda J. Cooper,Deputy Town Clerk Dated: July 27,2004 Re: Filming and Parking Permits Number of pages (including cover); 3 If total transmittal is not received,please call 631-765-1800. COMMENTS: Call me if YOU run into any problems. Good luck with the shoot ELIZABETH A.NEVILLE Town Hall,53095 Main Road TOWN CLERK C4 P.O. Box 1179 REGISTRAR OF VITAL STATISTICS z, z Southold,New York 11971 MARRIAGE OFFICERr` ` Fax (631) 765-6145 VV RECORDS MANAGEMENT OFFICER Telephone(631) 765-1800 FREEDOM OF INFORMATION OFFICER OFFICE OF THE TOWN CLERK TOWN OF SOUTHOLD FAX TRANSMITTAL To: Nadia Vellam From: Linda J. Cooper, Deputy Town Clerk Dated: July 27, 2004 Re: Filming and Parking Permits Number of Pages (including cover): 3 If total transmittal is not received,please call 631-765-1800. COMMENTS: Call me if you run into any problems. Good luck with the shoot o�os�FFot�.�oG ELIZABETH A.NEVILLE �� �� Town Hall, 53095 Main Road co TOWN CLERK W Z P.O. Box 1179 REGISTRAR,OF VITAL STATISTICS O Southold, New York 11971 MARRIAGE OFFICER A • ��� Fax(631) 765-6145 RECORDS MANAGEMENT OFFICER ! `1►a Telephone (631) 765-1800 FREEDOM OF INFORMATION OFFICER southoldtown.northfork.net OFFICE OF THE TOWN CLERK TOWN OF SOUTHOLD To: Chief Cochran, Southold Town Police Mike Verity, Building Department Bob Fishers,Fire Marshal Ed Forrester, Code Enforcement Officer Peter Harris, Superintendent of Highways From: Linda J. Cooper, Deputy Town Clerk Dated: July 27, 2004 Re: Filming Permit No. 015 In accordance with Town Code 44A-9 you are being notified that a Film Permit was issued to W Magazine/Fairchild Publishing. See following pages for a copy of the permit and application. o�$oFFOt,�oo ELIZABETH A.NEVILLETown Hall, 53095 Main Road TOWN CLERK y Z P.O.Box 1179 REGISTRAR OF VITAL STATISTICS O Southold, New York 11971 -6145 RECORDS P MARRIAGE ENT OFFICER y� �aO�� Tele hFaxo5ne 631 765-1800 FREEDOM OF INFORMATION OFFICER southoldtown.northfork.net OFFICE OF THE TOWN CLERK TOWN OF SOUTHOLD FILMING PERMIT NO 015 OF 2004 PARKING PERMIT DATE: THURSDAY, JULY 289 2004 TIME: 8:00 AM to 8:00 PM LOCATION: "67 Steps" Beach at Sound Road, Greenport o�g�FFO���oG ELIZABETH A.NEVILLE y� Town Hall, 53095 Main Road TOWN CLERK vs = P.O.Box 1179 �►' Southold,New York 11971 REGISTRAR OF VITAL STATISTICS O Fax(631) 765-6145 MARRIAGE OFFICER 'yifJo a0`' RECORDS MANAGEMENT OFFICER 1 jog ` Telephone(631) 765-1800 FREEDOM OF INFORMATION OFFICER southoldtown.northfork.net OFFICE OF THE TOWN CLERK TOWN OF SOUTHOLD FILMING PERMIT NO 015 OF 2004 PARKING PERMIT DATE: FRIDAY, JULY 29, 2004 TIME: 8:00 AM t0 8:00 PM LOCATION: "67 Steps" Beach at Sound Road, Greenport ' o�OS�fFO��coG ELIZABETH A.NEVILLE C* y� Town Hall, 53095 Main Road TOWN CLERK y Z P.O. Box 1179 REGISTRAR OF VITAL STATISTICS O Southold, New York 11971 MARRIAGE OFFICERy • O�� Fax(631) 765-6145 RECORDS MANAGEMENT OFFICER �O! `1►a Telephone (631) 765-1800 FREEDOM OF INFORMATION OFFICER southoldtown.northfork.net OFFICE OF THE TOWN CLERK TOWN OF SOUTHOLD To: Southold Town Attorney's Office From: Linda J. Cooper Dated: 6/17/04 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 W magazine/Fairchild Publishing by Nadia Vellam are attached hereto. Please review and advise whether these documents meet with your apfro)0al. Thank you. Approved as submitted Disapprove for the following reasons: )ignature RECEIVED JUL 2 7 2004 JUL 2 3 2004 L Southold Town Clerk TC. i Jul-22-04 01 : 31P Fairchild 2126303524 P.02 U!!LGIru'i LU.14 rAA A4AAVDOr.VV.r 'Ce), u4 1210 Ov:44 rAA Dol 190 0144 bULfkJ1ULV "Blair CL"A Wuv;j TOWN O;; souTtiOLD APPLICATION FOR FILMING/STILL PHOTOGP.AiPHY vZom ss ]Fxzw Ox TYPIC i�'PLiCi►Tloti aAXA= �•/J�''/4 PZBN= no _. lrirtA3 oP spxLIC7►ttT� _.__„�.-�u" � .. � . 34 . 'V�r !'VI • D.!Z� ]PRO=] xeancss wcm XX OF 0RGW %Z?#XXQK. A": bms-_ m +4d I, l GYrp 1 PROM: I z _ b30 —3Y 1,0 Z gy 6 945 _. .••a►.♦+•+.i�+r•..�t.aYrr�i RflN�.•�•ea.�.•.ifwr•e�.m•.aa..a•a.�w�wsa+ 13050= SYPB OF AC!l1VITY (a.*. #*tL*4 8iCCme t C'oatalrOSAl r T61eVtJ1Ldftr eat4109. Walwasime r e!e.)s vezats) xtaa 'r�(nl ar pt�oSav y+rrxi�ta/axosaGxaPxt[: . OACIP06 D WCATXQX1 19l attach a 1>t1QZ&1 Dheet. it Aeceisaiy_ Tawe air emeow = oMMoa x: airs. 1NA d►n \100m XUKM= or aevs xT =LoC IMW (tris s Cm= %*%=ZDf: 1 - 1Z j/ roK-) vowmim AM TY2)E 01, v c9a g AT TAC"Tzox. 49J)V clf 5 COW 6 V%O rv+C ? 17PSr Or syscIAL a=..vho rt S 1( .� •��rtwe . vyj, Atil 9PWZAL siy>natvxa Return to, Sauthold Town Clerk si*thold Town Hall 33093 Main Road P. O. Sox 1179 Southold, NY 11971 Jul-22-04 01 :32P Fairchild 2126303524 P.03 yr tau vv:&4 rate ooa too oA4o avuant AW auen 6L4W A 46 INDEMNIFICATION AGREEMENT TOWN OF SOLMHOLD Fff,mwG=JL'L PHOTOOPAPHY PERmrr The AppIk=t shall indemnify and hold harmless the Town from and agahM aQ sails,chime,demands or actions for any damage andlor igjury smstamed or nieged to be saSWO ed by RMY par4Y or Vartks iw cannectiop vvlth the perfarmaece of igadft or still pbotograpby by the Applicant,hie employees or amts or may subcontractor and iio case of sny such action b relight agahM the Towns the appifcant chsn inwiediately tnkks charge of and defend the same at bis own Cost and expense. in addition,the Applicant wM name me Torun as an additional insured on m'applicable policies- Signam.txe nate Printed mins Tim Jul-22-04 01 : 32P Fairchild 2126303524 P.05 44LCr#::• „• �,.,.�T•M.dxd?laAw.iv:nj. t o ......DTE a €rwsridw ► 7122104�1YTI eE¢•. THIS CERTFICATS IS ISSUED AS A MATTER OF INFORMATION RED group LLC ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER, THIS CERTIFICATE DOES NOT AMEND, EXTEND OR eM0 Plaza ALTA THE COVEIIAGE AFFORDED BY THE POLICIES BELOW. PO Box Soso i _^_ COMPANIES AFFORDING COVERAGE _— Jorlaha NY 11153-'9950 COMPANY 1518) 327-2100 A FEDERAL INSURANCE COMPANY I COMPANY — Falrehlld Publications, Ina. I 5 GREAT NORTHERN INS CO 7 N. 341h Gtrset COMPANYNaw York, NY 10001 C 87, Paul Fire 5 NSrine Ins. Co COMPANY D AMERICAN NONE ABsupmm GOBPAMY �`w'3<4R!f,tg6a#:k^'ft#^Y.aS fy:ilD:4,d'J, s1S':fA>ing....e�z.do•f.Jad.M.Yr.J%AJW.L.:.:r::&e:..:wPfr0a0.:w'1+:3 `M90CdCow•6Y9MM4 •eb/d' 'r.....a.s.rr•.:ao%R2:nOev%+0.ricf W�Sfis ........ IM �tri#ai.ea.ww:...rw:e.........,... .:'��Ga.i•:tS'«`t7v;r�3AYadatc::R•.,rixxa..a.•.,...�.......:.:b`•»o.,s:k•a...'1R.+�AYra�W?Aga,6o-8•e5i,1��06:tAws,...:.�,w.mei«.,.:..�•ao?.o:aesei»e...;:>.,y....'s;?gn?V?•»�,ad4&es . THISMTOCERTIFYTHATTHEPOLICIRBOFINSURANCELISTEDISELOWHAVEBEENISSUEDTOTHEINSUREONAMEDABOVEFORTHE POLICY PERIOD M a INDICATED,NOTWITHSTANDMANYREQLMREMENT,TERMOR CONDITIONOFANYCONTRACTONO'f HERDOCUMENT WITHRFSPECTTO WHICHTHIS CEATIFICA TE MAYBE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS BUBJBCT TO ALL THE TEAMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES,LIMITS SHOWN MAY HAVE BEFN REDUCED BY PAID CLAIMS_ ^ • FNwVAANE71 ----- .••• .10LICYNwIi/iil p01JilYEMI70YIVB POLICY8XPRA'rlo TYPE O .. ... LTB —�OATB(MWOOTYY) DATE IMMICIUMLIMnTI I A 44WO IALLJARLT" 8808118 7101104 7/01105 GENERAL AOOMOATE $ 7,000.0pp X COMMERCIAL DENEkALLIABILITY PRODUCTS•COMP/rIP AUG S 1,000:000 rn.\ .... � ........�__...r. ____ .. CLAIMS MADE�..=J OCCl1H j PERSONAL i ADV INJURY 3 1,001,000 OWNER's A CONTRACTOWS PROT EACH OCCLFff.HC-E f 1,000,000 X FOLL Inol. _— _ FIRE DAMAOC(Ary one firs),S —_— Per qac Limit j MED EXP(MY ars parsuo) S 10.000 B ALIYOMORILELIABE_ITY 71731672 12/31/03 12/81/04 LIMIT X ANY AUTO CONFINED SINGLE 2.000.000 ALL OWNM AUTOS DOUILY INJURY SCHEDULED AUTOS (Por Pmrw ) S X HIr1FD AUTOS .••_. ... ___.. .. BODILY INJURY _ X NON•OWNED A'JTOS (Per a=Idsn0 PROPERTY DAMAOC OApAOlLUUlEJTY AUTO ONLY-EA ACCIDENT f ANY AUTO ....:.: OTHER THAN AUTO Y. .::•:.:.:...:.....:......:.::: _ I _ EACH ACCII�ENt S AGGRIZOATE- C 1xa8BLIABX.ITV OK01500112 (fR18ARY) 11'01104 1101106 SACH OCCUM104CE f 6,000,000 X. tAAOAELLA FORM _ _6,000,000 OREA RiAN UMBRELLA FORM Retention S 10,000 MC2991614 tAOS) 12/31/03 i( WOAITFAB CD'YPBNEATTON AND 12/31/04 A 1•,.,:...:.: . 0 aFWYEwg'LUE�Y 902/8//16 (CAI 12/31/03 12131104 EL EACH A=0jh'f I I,000,000 Or THE PMPRIxEcul INCL 902981816 0L.MY,911 12131/03 12/31/04 EL DISEASE•0OLICY_LIMIT f-- PMTHERS/l7CECti1£v8 1,000.000 OFFICERS Are FXCLI 6L DISEASE rA EMPLOYEE f 1,000,000 OTHER A All Risk Personal 8008118 1141104 7101105 Llmlt: 1.000,000 Property of Others i PROCRIPTIONOFO ATIONB CATx)NFIIYENNX.iBftiwBClAl.Irt#A1a Cortlfle41e holder Is Inaluded es additlonol Insured as respects to photo sheat to take place an or about 7/26-25/04 In Southold, Nan York. (Lone Islandl Ifl Nago4lnel �'?e't?#?'i•I••7r#a'.XR 3�•;?x:re��Riss�,s d}t#'..''°'":`'.'��..�,. riE'�!r's�'.s6sia' '�. �.�'r s!! ... .e... .. �: •a#'8r<tdrxacs..;..z:x:r• 7A)}i+.7.1&. S'� ?E�,.;�ti.el a«a.'j m�`�rs K.k'.. ar• SHOULD ANY OF THE A11OV1 DESCRIBED POLICIES 09 OANCBLLBD g9FOp8 THE Town at Seufhefd EXFNATION DATE THEREOF,THE MWNO COMPANY Wil ENDEAVOR TO NAIL, Suffolk County. Nem York 30 DAYS WARTBN NOT=TO THE CZATIFICATE HOLDER NAMED TO THE LEFT, Town Nal I BUT FAL IRS TO MAB.SUCH NOTIOB BNALL MFOstr NO OBLIGATION OR Lu1ELIr1' 83001 main Read OF ANY NDID UPON THE CQYMANV. ITS ABBNTS OR RBPRESBNTATNIP. P.O. Box 1179 A THOM=P TA SOBthe(d. MY 11971 4 500107042 .. ........ •he ..... ,n...x k'm.aw. °'�t •t•d6%+E&:JR.cia��dAsaat►.aigr"rrs�rsra.�i.y '�'aix.p�' sgEse?§is$rrg C T FICATE: 001/001/ 00531 �suFFot,�oo 0 ELIZABETH A.NEVILLETown Hall,53095 Main Road TOWN CLERK CA : P.O. Box 1179 REGISTRAR,OF VITAL STATISTICS O Southold, New York 11971 MARRIAGE OFFICER • � Fax(631) 765-6145 RECORDS MANAGEMENT OFFICER ! `�►a Telephone(631) 765-1800 FREEDOM OF INFORMATION OFFICER southoldtown.northfork.net OFFICE OF THE TOWN CLERK TOWN OF SOUTHOLD To: Chief Cochran, Southold Town Police From: Linda J. Cooper,Deputy Town Clerk Dated: 7/23/04 Re: Filming Permit Transmitted herewith is the application of W magazine/Fairchild Publishing by Nadia Vellam for a Filming Permit. In accordance with Section 44A.3 of the Town Code please review the application and advise of approval or disapproval of the application and whether a traffic control fee is required and the amount needed. �S%3EFo�,��o �O G ELIZABETH A.NEVILLE Town Hall, 53095 Main Road � �� TOWN CLERK P.O. Box 1179 REGISTRAR OF VITAL STATISTICSO Southold, New York 11971 MARRIAGE OFFICER y • ��� Fax(631) 765-6145 RECORDS MANAGEMENT OFFICER ��l �a Telephone(631) 765-1800 FREEDOM OF INFORMATION OFFICER southoldtown.northfork.net OFFICE OF THE TOWN CLERK TOWN OF SOUTHOLD To: Southold Town Attorney's Office From: Linda J. Cooper Dated: 6/17/04 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 W magazine/Fairchild Publishing by Nadia Vellam 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 POLICE DEPAQ-TMENT TOWN Of SOUTKOLD CARLISLE E. COCHRAN,JR. Chief of Police Telephone Emergency Dial 911 RECEIVED MEMORANDUM JUL 2 3 2004 Southold Town Clerk TO: Linda Coope,Deputy Town Clerk FROM: Chief Carlisle E. Cochran,Jr. DATE: July 23, 2004 RE: Application for Filming/Still Photography As per Local Law No. 6-2001, Section 44A.3, it is the recommendation of the Chief of Police that application dated July 22,2004, WMagazinelFairchild Publishing by Nadia Vellam,be APPROVED. As per Section 44A.4,Traffic Control Fee,there is NO FEE recommended at this time as there is no need for police assistance. 41405 Route 25 • P.O. Box 911 • Peconic, N.Y. 11958 Administrative (631) 765-2600/2601 9 Fax (631) 765-2715 07/22/2004 10:14 FAX 12124992083 G&J 0 004 .ZZ/UI u4 Ltt[J Ua:14 rAA 041 100 0140 bUU1'!lULV '1'UIV14 (A-l"K2l WUUJ TOWN OF Sa'UTHOLD . APPLICATION FOR FILMING/STILT, PHOTOGRAPHY yXiva x PR22i'1' OR tYPs A ZoICATION DATE= L2`Q PERMIT 200: 2Tb2i8 of AP'.P1.=CAD7T� ,L, !� y� MR=7+1�d ADDfLS89: �5 2, S� �l tel[�P,V{ xl 1,4- — pHw,os: 2ZAM or OROANZZATZON. 00HPA": puma; (Z I—�-1'36 " .� l 6 •aairfar�f w.f.ff.►.►a.iali M.►�41'i Rlr �f+w�arffa�ffifw:wf�+Rtf♦fffff*.**wove* .bage n rn% OP NCT=TY (e.g. Notioa 8ictuse, CoMMrC161, TCIOV1910a, COLCAI09. tiagazimm, ete.?: T1d1?E(S3 AM TMM(8) Or PR0P083V7'YI.NIN(:/VX01TOGP")ff: 9AO909= LOC36=0v(S) ar F=L4cnQ/P8o7 cmLxVH?: attach ad4it±=a1 sheet, it 'A4Ce98aLy. as t8ftem amass AT SzsE. wadi o� WON) a�ss� OF t(saws XA"T2cw MST a est %2TC% nsnj I: 'l0 r 12 des AND TYP00 Or vwmctcs AT LOCATZON{ �yel.��l� S co v s IM9}WhOw►C stings oi� SYNCZAL EQUMPN -1r, 211 a4l, n un Siyzsature • Return to: Southold Town Clerk Smiuthold Town Hall 53095 Main Road P. O. Box 1179 Southold, NY 11971 ' JUL 2 7 t'' 07/22/2004 10:14 FAX 12124882083 G&J 10005 z'/U i U4 AWFJ Uy:14 FAL 671 '160 6140 SULUXULO TUWN CL xr& 10j 004 INDEMNIFICATION AGREEMENT TOWN OF SOLrMOLD F,LmwG/svLL P110TOGI2APHY PEP-NUT The Applicant shall indemnify and hold harmless the Town from and against all snits,claims,demands or actions for any damage and/or injury sustained or alleged to be sustained by any party or parties in connection with the performance of filming or still photograpby by the Appif¢avt�his employees or agents or any subcontractor and in case of any such action brought against the Town,the applicant shall immediatcly take charge of and defend the same at his own cost and expense_ In addition,the Applicant will name the Town as as additional insured on any applicable policies. Signature Date t6u IP-Y\ov�n Printed name Title ■a�■ t}:; a ORA TE MMIDCIPY': > ' i MlibIfUC1iR ....,.....................::.::.....:::::::,.�.:,::...;.}:.:>}:x:;::;^:;';:;>.:.:................... .,. .:........>,...,.:;;�.:..}:x?.}::<?<;.i.•:.:,•+:,::. 7122104 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION BWD Group LLC ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR BWD Plaza ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. PO Box 9050 I COMPANIES AFFORDING COVERAGE Jar Icho NY 11753-8950 ! COMPANY (518) 327-2700 i INsUAND '"-" -- ___ ____ A FEDERAL INSURANCE COMPANY COMP_ Fairchild Publications, Inc. B GREAT NORTHERN INS CO 7 W. 34th Street COMPANY Now York, NY 10001 C ST. Paul Fire i Marine Ins. Cc COMPANY D AMERICAN HOME ASSURANCE COMPANY .....................�-..:.. .r.....n....,v:•.t:w:...................:.;:::.::.:.:!!::.::!}:;4.}::.:;:}.:;•i:.i:.:..:...y:..:..;:>:;�^:y?:�::%}:C:i:;::<i?:?:v:�'i>r".::: •:::rr:�.,i.;:ty:v..n.:..........w•:.;,.,......`::•.�:::.y. .....................:.............../....,.........:..:.:.r....,..,....,.................. ..............:......................:...::..:..:.....r................:ii>isti:i^}::}....:..i:i,:.._................... ..:::..}t4:K;•.}::?.::::•:`::}:::!:!?;!i{i:.:i%: ,::::::?::•:N::....:..........v;:..,::;.•.;....... v::::v.�:.vv:.:�!?..\.:::::n;......:..:�•�-n�vnvn v.v::.::v:}}::i:<:!:i::ii.;:�i: ...............................:.:...::::::::::m•:.,•;...:....v.:,":.�:.::::::::::::::::�::::.......... ...::..:::r,.:..Si:•::i:.:.,•:•:::::R:.�}.::.�::::.v:i:tvi:L:t:u4?tiry::•}:?v'}.:i•}:�•i}:$:•:v'::�}}:�:Y. '::.�•::\_C: ••' THIS IS TO CERTIFY THAT THE POLICIE S OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED,NOTWITHSTANDINGANYREQUIREMENT,TERMOR CONDITION OFANYCO NTRACT OR OTHERDOCUMENT WITHRESPECTTO WWICHTHIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES,LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. T I TYPE OF INSURANCE POLICY NUMBER POUCY EFFECTIVE POLICY EXPIRATION DATE(MWDD/YY) DATE(MMIOD/YY) LIMIT$ A GENERALLIABLITY 6908115 7/01104 7/01/05 GENERAL AGGREGATE $ 2,000,000 X COMMERCIAL GENERAL LIABILITY PRODUC7S•COMP/OP AGO $ _ 1,000,000 CLAIMS MADE❑X OCCUR PERSONAL 6 ADV INJURY $ 1,000,000 OWNER'S d CONTRACTOR'S PROT EACH OCCURRENCE --s-1,000,c00 X FDLL Incl. FIRE DAMAGE(Any one fire) $ Per Coo Limit MED EXP(Any one person) S 10,000 B AUTOMOBLEUABLITY 77731872 12/31/03 12/31/04 X ANY AUTO COMBINED SINGLE LIMIT S 2,000,000 ALL OWNED AUTOS BODILY INJURY SCHEDULED AUTOS (Per person) S X HIRED AUTOS X NON-OWNED AUTOS BODILY INJURY $ (Per accident) PROPERTY DAMAGE $ OARAOELIABILITY AUTO ONLY•EA ACCIDENT $ ANY AUTO OTHER THAN AUTO ONLY: EACH ACCIDENT $ AGGREGATE $ C EXCESSLIABLITY aK00500112 (PRIMARY) 1/01104 1101105 EACH OCCURRENCE $ 51000,000 X1 UMBRELLA FORM AGGREGATE $ 5,000,000 OTHER THAN UMBRELLA FORM Retention $ 10,000 D WORKERS COMPENSATION AND WC2991814 (AOS) 12/31/03 12/31/04 XW Ate' H• - D THE PROPRIETOR/EMPLOYERf'UABLITY WC2981815 (CA) 12/31/03 12131/04 EL EACH ACCIDENT $ 11000,000 D PARTNERS/EXECUTIVE INCL WC2981816 (IL,NY,WI) 12/31/03 12/31/04 EL DISEASE-POLICY LIMIT $ 1,000,000 OFFICERS ARE EXCL EL DISEASE-EA EMPLOYEE $ 1,000,000 OTHER A All Risk Personal 6908116 7/01104 7/01/05 Limit: 1,000,000 Property of Others DESCRIPTION OF OPERATIONSLOCATIONiVEHICLESISPECIALITEMS- Certificate holder is included as additional Insured as respects to photo shoot to take plata on or about 7/28-29/04 In Southold, New York. (Long Island) IW Magazine) MU SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE,•'•• Town of Southold EXPIRATION DATE THEREOF, THE ISSUING COMPANY WILL ENDEAVOR TO MAIL Suffolk County, New York 30 DAYS WRITTEN NOTICE TO THE CERT04CATE HOLDER NAMED TO THE LEFT, Town Noll BUT FAILURE TO MAL SUCH NOTICE 8HALL IMPOSE NO OSUGATION OR LIABILITY 53095 Main Road OF ANY KIND UPON THE COMPANY, ITS AGENTS OR REPRESENTATIVES. P.O. Box 1179 AUTHORIZED R P tENTATIVE Sorthold, NY 11971 (4 :;«•:;.}:.:}:..;.;:}.:..:...:..... ,............ : ...::.::.. ,,}•.:;,.}::::>;:.;:'::.;..;;.:. :::.::.::;:.. • 500107042 F.n h:< }hsb .::j:f i�' .. ......:::.::.......... :....gin.;•..v .. .. ....::n:•.::;?ilii:�:4i::.�::::.:........... .;>+y:.::,:•;;............;....... C RTIFICATE: 001!001/ 00531 Jul -22-04 01 : 31P Fairchild 2126303524 P _02 U1!GG/ZUU4 LU.14 ilL1 1:AA'+oaivvV �+��+ - UU, u4 lnu uv.44 rAA DOI 10z v140 JUt11'l1ULU 1LA14 (:LliKll W1 TOWN OF SaUTriOLD APPLICATION FOR FILMINC/S'TILL PHOTOGRAPHY 8> a PRAT CA TYPIC ]ova OP h"I'ICaurl �a u ✓�— AV ltA1X. WY or oRawz XTXQK. C=vA : W XAss.3xs �S 354 __. 1�i/0 31 4. v`I� Pi-VL o _. -V kvi I dYro P89mi8: Z 1030 —3y-) 0 •2 LQ , .ff0►.�s��.i��r..�.1!}Yr�ri.e}�a�.•��f�.�4@f+lA�.l�4l.f•!f.!••r����l�• br4CC3tX0 TYPE OF ACM=TY (e.g. 1'lotio74 Bictuze, camArctal, 'Ialevf LOU, catalog. Nawasdsft, eta.)2 51noo W vnTa(s) A>b rrKa(e) OP PPOPOSVO VTX2"1A2/VK0TOr-wVAPHY. , wed JU1 -CAuv5dAm, J1q .2�o . _^. tim 40°a 1AOp08� l.vCAT=O'IS�) oY YtLiLI194/?BQTo@AA1?HY: attach a•'1.Y>tioaal Blleet. 1[ AeceBeity. X&Wx a* eva& r Ar aeAraa AT errs. NAd►A Ve1tV XURO - ICP X011& 7►T z O"022cs MRM & mw TDf mtmzD1 s I - 12 ra K-) 11pTIasm AM TYPE of, V1=CZ.SP AT 7.40mTS011: A �Vl��C.l�S C.OGY S��p(nD'YV1C ? T%vv OFsn11oTAL $0=-hamr: AW aPSCZLL erg: sdynatu>re Return to: Southold Town Clerk S6iuthold Town Hall 33095 Main Road P. O. BOX 1179 Southold, NY 11971 7/ �/o �- Jul -22-04 01 : 32P Fairchild 2126303524 P _03 W% LAU 4Y=14 WA.& 94A /00 0140 OUVAMU"W 1UWS 6Ai6AA goUU4 INDEMNIFICATION AGREEMENT TOWN OE SOUTHOW FI[dv VO SULL PROTC1OR"HY PERwr The Applicant than indemnify and hold harmless the Town from and against all suits,claims,demands or actions for any dwuge and/or injury swtained or alleged to be saeftined by any prim or parties in connection w!th the PftK6rmance of Mni g or still photography by the Appllcant,his employees or agmts or any mbeontractor and io case of any such action brought agstnat the Torn,the appifcant shall immediately take charge of and defend tate same at kh awn cost and expense. in addition,the Applic=t wtH name the Town as ab additional insured on any applicable policies- Siguascae Date Printed name �In ro �vyay rw jA N1��oil Title Jul -22-04 01 - 32P Fairchild 2126303524 P.05 �• •.fr;. /�/� kiiini '�! 'y' :t cz +ss^a 8' >� ;....:: ATE INM1001YT1 "/331L1t�815..:a:'!: L1A? e n ::iii a 7122!01 � .�,:'t�•..gat.: -F .4-1 >ZYldb(7�Ifli""'' THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION 8N0 group LLC ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER, THIS CERTIFICATE DOES NOT AMEND, EXTEND OR BWO Plaza ALTER THE COVERAM AFFORDED BY THE POLICIES BELOW_ PD Box 9050 ; COMPANIES AFFORDING COVERAGE Jericho MY 11153-11960 COMPANY (516) 327-2100 A FEDERAL INSURANCE COMPANY I COMPANY FatrchlId Publloatians, Inc. I g GREAT NORTHERN INS CO 7 W, 341h Strait COMPANY Now York, MY 10GD1 C ST, Paul Firm A Marine Ins_ Ca COMPANY D AMERICAN NONE ASSURANCE COMPANY p,. }L�.�< s:.,:,..,. ,•. S:+r ..v..... .....v.:,i.e'.n::;<;:..r.:..:<::.....: .. ,.1..:5g:lt/•p...o-.:.: ..... ....•. '. ...:::«.2k.nb::tae....`..•. .a#.::w,.<i::,i .., ........,.. .. : .s.. ...., : knY.,ri.refk.f:s:<•an.a-.:.t r.&: n::•: ::<.: THIS IS TO CERTIFY THAT THE POUCIF,S OF INSURANCE LISTED 13ELO W HAVE BEEN ISSUED TO THE INSUREO NA MED ABOVE FOR THE POLICY PERIOD INDICA TED,NOT W ITHSTANDING ANY REOUIREMENT,TERMOR CONDITION OFANY CONTRACTOR0 i HERDOCUMENT WITHRFSPECTTO WHICHTHIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN 15 SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES,LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. TYPE OP W EHfLANCE wOLMY Nl1N1EER POLICY EMFECYIVE ✓•OLIGY 1XPPATION LNa17E LTR DATA(MMIDONY) DATE IMMIDD(M Al.OX-NCRALL1AEE11V 6508115 7/01104 7/01105 GENERAL A00 GATE S =10DO,000 X COMMERCIAL GENEHALLIABILITY PRODUCTS-COMPIDP ACM S 1,000,000 CLAIMS MAGI X accuH j PERSONAL 6 ADV INJURY 1 1,000,000 OWNER'S A CONTRACTOR'S PROT EACH OCCUFW ACE S 1,000,000 X FULL Incl, _ FIRE DAIZ (Arty ona(irs) S Par Qoo Limit— ••• { j MED EXP(MY une Perron) S 10,000 B AUTOM08LCLIABLITY 71731872 12/31/03 12/91/01 COMBINED SINGLE LIMIT S X ANY AUTO 2.000.000 ALL OWWD AUTOS pODILY INJURY —__— SCHEDULED AUTOS (I'or person) X1 HINFLy AUTOS - BODILY INJURY 1 X NON-OWNED AUTOS (Pet ascidenl) -- PROPERTY DAMAGE OARAOE LIA9ILRY AUTO ONLY-EA ACCIDENT S ANY AUTO OTHER THAN AUTO ONLY. .:: :.::..:...:....... :.....:.::.: EACH ACCMENI S AGL*GGATE S C EXCXissLu91LITY OKOS500112 (PRINARY) 1/01/04 1/01106 EACH OCCURRENCE f S,000,OOD X UMBRELLA FORM AOOf(EOATE s. . _5,000,000 OTHER THAN UMBRELLA FORM Ratantion - s 10,000 D WORKERS COMPENSATION AND WC2881814 (AOS) 12131/03 12131104 %WC S ATU• O H-,.;;,.•;,;,;•,; D iMFLOYERS'LIAELITY NC2681815 (CAI 12/31103 12/31104 EL EACH ACCIDENT = 1,080,000 D, THE PROPRIF.TOR� INCL .. _. PARTNERS/t%ECUIWI WC2981816 (1L.NY,111) 12131/03 12/31/04 EL DISEASE-POLICY LIMIT S 1,000.800 1 OFFICERS ARC: F1 FXCLI EL DISEASF-FA EMPLOTF:F S 1,000,000 OTHER A All Risk Personal 6208116 1101/04 1101/05 Limit! 1,000.000 Property of 04h■es i DisCAIPTIONOFD ATIONI CATIONtfYENICLi9I9FECIAI ITEMS Cortlflaat• holdor Is included as additional Insured as respects to photo cheat to take place an or about 7128-29/04 In Southold, Now York. ILDn1 Islandl (N Magazine) t... ..:.:... SHOULD ANY OF THE A11OVE 01190191D POLICE$9E 04NCSLUM DPOpE THE Town of Southold EXPIRATION DATE THEREOF, THE NIEUINO COMPANY Wil ENDEAVOR t0 MAL Sof f i I k County, Now York 30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, Town Hall BUY FA6.URE TO MAL SUCH NOTICE SHALI.IMP099 NO OUJOATION OR LIAEL[TT 69006 Main Road DF ANY KIND UPON THE COMPANY, ITS AOENT4 OR RAPR1s9NTATMO. P.O. Box 1179 AUTHOR17JiPit v6"TATME Soythoid, NY 111171 a 500101042 &::.::.. y,, .•,Q, ys�p. ..�.:+.�i::F<Frri.4;:£.,•Lei$:rQ:Y.::e.i:.?e�:.>s<ta<.:Q,:R::S::::Rx:s3:aECiN.iA.Ali:s.::$'t,9'' • 'Rk a i�:.. 4e5IM1.bIY•,T/Y1. :?t:ii ..f. '6.{>.2::::,:,3s,�,'.,Y::,:/;k:•�':,rb:V:4<.is s::. 5:i#'i:' •,:.'$,t,8iitt"e "E 'AeWe sRI �'n { TIFICATE: 001/091/ 00031 ;, n.ta.wrlwTrrate:: � .,.�--�ooau�uv To THE uoHr ro vow TRt�E wA citlbank ---- No '44387434966 Citibank,N.A.,New York,NY 10_86 FC# 015 FA# 047 $10.00 ONL PICDATE O 7 % 2 2 % 0 4 220 075-03 Ck. Ser.# 387434966 * * * * * * * * 3 8 O 0 0 ! ****THREE HUNDRED EIGHTY DOLLARS**** PAY TO ****Town Ot Southold**** THE awn ORDER t °" OF NAME OF REMITTER Nadia Vol lam Dewar A ADDRESS 153 East 87th Street, 1 3A NYC 10128 BY � Issued by Integrated Payment Systems Inc..Englewood,Colorado q IZE I ATURE To Citibank,N.A..Buffalo,NY 790 S4 20 1:0 2 20008681: 21h60 3 a ?4 349P.6L."' ktti,.p e. rr... i Citibank• --- 387434968 k Citibank,N.A.,New York,NY 10_86 i FC# 015 FA# 047 $10.00 ONL PIC DATE 0 7 2 2 0 4 220 075-03 Ck. Ser.# 387434968 * * * * * * * * 2 5 O 0 0 ****TWO HUNDRED FIFTY DOLLARS**** PAY TOI THE ****Town. Ot S0Uth0Id**** ry I ORDER OF NAME OF REMITTER Nadia Vel tae ADDRESS 153 East 87th Street, S 3A NYC 10128 BY � Issued by Integrated Payment Systems Inc.,Englewood,Colorado AUTHORWD SIONA U To Cltlbank,N.A.,Buffalo,NY 4�-� 790 54 21i' 1:0 2 20008681: 2800 38 74 34968 2ii' tNXI0001LIMEWUPIM 7h tr RK ; c trbank' � � .�_ � ! 387434967 Citibank,N.A.,New York,NY 1D 86 FC# 015 FA# 047 $10.00 ONL PIC DATE 0 7 / 2 2 0 4 220 075-03 Ck. Ser. # 387434967 * * * * * * * * 2 5 0 . O 0 ****TWO HUNDRED FIFTY DOLLARS**** PAY TO ****Town Ot SOUthold**** THE ORDER OF NAME OF REMITTER Nadia Vel lam :c ADDRESS 153 East 87th Street, 1 3A NYC 10128 B K Issued by Integrated Payment Systems Inc.,Englewood,Colorado A ORIZED Id TORE To Citibank,N.A.,Buffalo,NY 111790 54 2118 il:0 2 20008681: 2800313 7434